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QlJIZ-COMPENDS 


Genito-Urinary  Diseases 
AND  Syphilis. 

HIRSCH 


FOR    MEDICAL    STUDENTS. 


WILCOX.  MATERIA  MEDICA  AND  THERAPEUTICS:  IN- 
CLUDING PHARMACY  AND  PHARMACOLOGY.  By  Rey- 
nold Webb  Wilcox,  m.a.,  m.d.,  ll.d.,  Professor  of  Medicine  (Retired) 
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POTTER.  THERAPEUTICS,  MATERIA  MEDICA,  AND 
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BEARD.  OPHTHALMIC  SEMIOLOGY  AND  DIAGNOSIS.  By 
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O'REILLY.  A  MANUAL  OF  PHYSICAL  DIAGNOSIS.  By 
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HENDERSON.  LESSONS  ON  THE  EYE.  By  Frank  L. 
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ing Oculist  to  the  St.  Louis  Hospital,  the  Wabash  Railway,  etc.  Fourth 
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HAWK.      PRACTICAL    PHYSIOLOGICAL    CHEMISTRY.      A 

Laboratory  Handbook,  designed  for  use  in  Courses  in  Practical  Physio- 
logical Chemistry  in  Schools  of  Medicine  and  Science.  By  P.  B.  Hawk, 
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THORINGTON.  REFRACTION  AND  HOW  TO  REFRACT. 
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P.  BLAKISTON'S  SON   d,  CO.,  Publishers,   Philadelphia 


GENITO-URINARY  DISEASES 
.       AND  SYPHILIS 

HIRSCH 


From  The  Southern  Clinic. 

"We  know  of  no  series  of  books  issued  by  any  house  that  so  fully  meets  our 
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Illustrations  and  16  Plates  of  Nerves  and  Arteries,  with  Explanatory  Tables,  etc. 
BRUBAKER.     PHYSIOLOGY.     Twelfth    Edition,    with   new    Illustrations    and    a 

Table  of  Physiological  Constants.     Enlarged  and  Revised. 
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and  Improved.     With  104  Formulae  and  195  illustrations. 
LEFFMANN.     CHEMISTRY,   Inorganic   and  Organic.     Fifth   Edition.     Including 

Urinalysis,  Animal  Chemistry,  Chemistry  of  Milk,  Blood,  Tissues,  the  Secretions, 

etc. 
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Text -book  of  Pharmacy. 
BALLOU.     VERTERINARY  ANATOMY  AND   PHYSIOLOGY.      With   29   graphic 

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Illustrated.     Containing  all  the  most  noteworthy  points  of  interest  to  the  Dental 

Student,  and  a  Section  on  Emergencies. 
HATFIELD.     DISEASES  OF  CHILDREN.     Colored  Plate.     Third  Edition,  Revised 

and  Enlarged. 
ST.  CLAIR.     MEDICAL  LATIN.     Second  Edition. 
SCHAMBERG.     DISEASES  OF  THE  SKIN.     Fourth  Edition ,  Revised  and  Enlarged . 

108  Illustrations. 
RADASCH.     HISTOLOGY.     Second  Edition.     With  127  Illustrations. 
HIRSCH.     GENITO -URINARY    AND   VENEREAL    DISEASES,    AND    SYPHILIS. 

Second  Edition.     With  74  Illustrations. 

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Schematic  drawing  of  the  urogenital  apparatus  illustrating  the  routes  by  whiili 
the  various  structures  are  involved  in  ascending  and  descending  infections. 


1.  Meatus  urinarius, 

2.  Penile  urethra. 

3.  Membranous  urethra. 

4.  Prostatic  urethra. 
5    Prostate  gland 


6.  Ureteral  orifice. 

7.  Ureter. 

8.  Renal  Pelvis. 

9.  Kidney. 

10  Ejaculatory  duct. 
16   Os  pubis. 


11.  Seminal  vesicle. 

12.  Vas  deferens. 

13.  Epididymis 

14.  Testis. 

r  s;    Bladder 


BLAKISTON'S      ?    Q  U  IZ-CO  MP  EN  D  S  ? 

A  COMPEND 

OF 

GENITO-URINARY 
DISEASES  AND   SYPHILIS 

INCLUDING  THEIR  SURGERY  AND  TREATMENT 

BY 
CHARLES  S.  HIRSCH,  M.  D. 

FORMERLY   ASSISTANT  IN  THE   GENITO-URINARY   SURGICAL   DEPARTMENT,  JEFFERSON 

MEDICAL  COLLEGE   HOSPITAL;   CONSULTING  PHYSICIAN,   SOCIAL  SERVICE 

HOSPITAL  AND  JUVENILE  PROTECTIVE  ASSOCIATION,  PHILADELPHIA 


SECOND  EDITION 
WITH  74  ILLUSTRATIONS 


PHILADELPHIA 

P.   BLAKISTON'S   SON   &   CO. 

1012   WALNUT   STREET 
1912 


Copyright,  1912,  by  P.  Blakiston's  Son   &  Co. 


Anon 


MAY  1    1948 


Printed  t>y 

The  Maple  Press 

York.  Pa. 


Q 


en 


^ 


TO 
ORVILLE  HORWITZ,  B.  S.,  M.  D. 

PROFESSOR  OF   GENITQ-URINARY  SURGERY, 

JEFFERSON   MEDICAL   COLLEGE 

THIS  VOLUME  IS  RESPECTFULLY 
DEDICATED 


PREFACE  TO  SECOND  EDITION. 


In  this  edition  the  author  has  carefully  revised  the  entire  work, 
and  added  considerable  new  matter,  the  object  being  to  present, 
throughout,  the  subject  as  complete  as  possible,  at  the  same  time 
making  it  thoroughly  adaptable  for  the  use  of  students,  and  for 
reference  by  the  practitioner. 

A  number  of  new  cuts  have  been  added;  notably  that  showing 
the  pathological  lesions  of  the  verumontanum,  and  another,  an 
original  dissection  of  the  prostate  and  seminal  vesicles  by  Barnett. 
These  two  subjects  have  been  given  considerable  attention  owing  to 
the  recent  contributions  made  in  the  diagnosis  and  treatment 
of  diseases  of  these  structures.  The  use  of  bacterins,  epidymotomy, 
vasotomy — anastomosis  of  the  vas  deferens  for  the  cure  of  sterility 
— fulguration  treatment  of  papillomata  of  the  bladder,  use  of  the 
Buerger  urethrocystoscope,  and  the  phenolsulphonephthalein  test 
have  been  included. 

The  Chapter  on  Syphilis  has  likewise  been  materially  increased 
owing  to  the  recent  advances  in  the  diagnosis  and  treatment  of  this 
disease.  The  method  of  obtaining  the  spirochaeta  pallida,  cultiva- 
tion of  the  organism,  its  staining  and  the  use  of  the  dark  ground 
illuminator,  are  dealt  with.  The  serum  diagnosis  of  syphilis  is 
discussed  at  length,  setting  forth  the  various  phases  of  this  very 
interesting  study,  explaining  in  detail  the  principles  and  technic  of 
the  Wassermann  and  Noguchi  tests  in  particular.  The  treatment 
of  syphilis  by  the  use  of  salvarsan  is  discussed  briefly  and  yet  suffi- 
ciently thorough  so  as  to  enable  the  reader  to  appreciate  its  value, 
various  methods  of  administration,  advantages  and  disadvantages, 
elimination  and  untoward  effects  of  this  important  addition  to  the 
therapeutic  equipment  of  the  treatment  of  syphilis.  The  per- 
manency of  its  effects  and  its  influence  on  the  Wassermann  reaction 
is  clearly  set  forth  in  so  far  as  the  experience  to  date  will  permit. 

Charles  S.  Hirsch. 
908  Pine  Street,  Phila. 

ix 


PREFACE  TO  FIRST  EDITION. 


The  need  of  a  book  that  epitomizes  the  mass  of  matter  in  the 
standard  text-books  was  realized  by  the  author  in  the  course  of  his 
duties  as  quiz  master. 

To  meet  this  need  has  been  his  aim,  and  he  hopes  that  the  book 
will  facilitate  the  student  in  mastering  the  important  points  in  the 
diagnosis  and  treatment  of  genito-urinary  surgery,  venereal  diseases 
and  syphilis. 

The  author  has  striven  to  make  more  than  a  compend,  as  he 
knows  that  many  practitioners  will  welcome  a  compact  book  that 
treats  of  these  diseases  tersely.  He,  therefore,  has  omitted  un- 
necessary detail  and  the  very  rare  affections. 

A  description  of  the  surgical  anatomy  of  the  organs  of  the  uro- 
genital tract  precedes  the  technic  of  the  various  operations;  and  the 
newer  aids  to  diagnosis,  e.  g.,  cystoscopy;  ureteral  catheterization; 
cryoscopy — urinary  segregation — ^X-ray,  etc.,  are  fully  dealt  with. 

Likewise  the  subject  of  treatment,  both  medicinal  and  surgical. — 
The  remedies  and  formulae  recommended  are  those  advocated  by 
the  most  eminent  urologists  and  syphilographers,  and  used  by  the 
writer  and  his  colleagues  at  the  Jefferson  Medical  College  Hospital. 

To  Casper's  Text-book  of  Genito-urinary  Diseases,  Deaver's 
Enlargement  of  the  Prostate,  Taylor's  Treatise  of  Genito-urinary, 
Venereal  Diseases  and  Syphilis,  the  American  Text-book  of  Genito- 
urinary Diseases — and  to  Fournier,  Hutchinson,  Ricord,  and  other 
noted  authors,  the  compiler  cheerfully  acknowledges  his  indebted- 
ness. 

His  thanks  are  also  due  to  Mr.  C.  V.  Brownlow,  of  P.  Blakiston's 
Son  and  Co.,  for  his  criticism  and  suggestions  in  the  preparation  of 
the  volume. 

If  the  amelioration  of  suffering  and  the  avoidance  of  hereditary 
taint  in  the  unborn  are  furthered  by  this  little  work,  the  author's 
task  will  not  have  been  unavailing. 

Charles  S.  Hirsch. 
xi 


TABLE  OF  CONTENTS. 


CHAPTER  I. 


Examination  of  the  Urine:  General  technic;  reaction; 
amount — odor — color — transparency  and  consistency, 
specific  gravity;  average  composition  of  normal  adult 
urine — urea — chlorides — ^phosphoric  acid  (earthy  and 
alkaline  phosphates),  indican;  abnormal  constituents: 
Albumin — -glucose,  biliary  pigment.  Urinary  sedi- 
ments: Mucus,  pus,  blood,  casts,  epithelia.  Epithe- 
lia — prostatic  secretion,  testicular  and  seminal  vesicu- 
lar secretions,  pseudomembrane,  filaria  sanguinis 
hominis  and  echinococcus  cysts,  bacteria — technic 
in  examining  for  tubercle  bacilli — smegma  bacillus, 
Ehrlich's  diazo-reaction — fat — urinary  calculi — uric 
acid  calculi,  uratic  calculi,  calcium  oxalate — mixed 
phosphate  calculi — calcium  phosphate  calculi — Urin- 
alysis record  i~i7 

CHAPTER  n. 

Urethritis:  Simple  and  specific — the  gonococcus,  technic 
for  the  examination  of  gonorrhoeal  discharge,  technic 
of  Gram's  method — inoculation  upon  culture  media, 
infectiousness  of  urethral  discharges,  acute  anterior 
urethritis — examination  of  the  urine  in  urethritis. 
The  two  glass  test — relapse  or  exacerbations  of  symp- 
toms. Complications  of  anterior  urethritis  in  the 
male:  Gonorrhoeal  ophthalmia,  periurethral  infection, 
— inflammation  of  the  preputial  follicles,  retention  of 

xiii 


XIV  CONTENTS. 

urine — Cowperitis,  gonorrhoeal  rheumatism,  differ- 
ential diagnosis  of  gonorrhoeal  and  simple  rheuma- 
tism, bacterin  and  serum  therapy,  bubo — balanitis — 
posthitis  and  balano  posthitis  vegetations — lymphan- 
gitis— acute  posterior  urethritis — gonorrhoeal  cystitis — 
chronic  urethritis,  the  endoscope,  treatment  of  acute 
anterior  urethritis,  complications  of  posterior  urethri- 
tis— epididymitis  and  epididymo-orchitis — epididy- 
motomy,  chronic  orchitis — congestion  of  prostate 
(acute,  subacute  and  chronic),  gonorrhoea  of  rectum 
and  of  the  mouth — diseases  of  the  verumontanum — 
gonorrhoea  in  the  female — chronic  urethritis  in  the 
female,  vaginitis,  vulvitis,  bartholinitis,  inflammation 
of  the  uterus  and  its  appendages,  treatment  of  gonor- 
rhoea  in    the   female 18-63 

CHAPTER  III. 

Affections  of  the  Penis:  Phimosis — circumcision,  para- 
phimosis, dorsal  incision,  balanitis  and  balano  posthi- 
tis, herpes  progenitalis,  papillomata — carcinoma — 
sarcoma — hypospadias,  epispadias,  juxtaurethral 
'  sinuses,  periurethral  abscesses,  abscess  of  Cowper's 
glands,  priapism,  neuralgia,  elephantiasis,  lymphan- 
gitis, phlebitis,  cavernitis  or  penitis,  benign  new 
growths,  fracture  and  curvative  of  penis 64-79 

CHAPTER  IV. 

Stricture  of  the  Urethra.:  Anatomy  and  physiology  of 
urethra,  urethral  calculi,  foreign  bodies  in  the  urethra 
— stricture  of  male  urethra — stricture  of  female  ure- 
thra, congestive  or  inflammatory  stricture,  traumatic 
stricture,' classification  of  stricture — congenital  stricture 
— spasmodic  stricture,  organic  strictuFe — pathology 
of  stricture — varieties,  location — symptoms,  complica- 


CONTENTS.  XV 

tions — exploration  of  the  urethra,  examination  of 
strictures,  technic  of  introducing  catheter  or  sound — 
treatment  of  stricture  in  anterior  urethra,  instruments 
for  operation  upon  the  urethra — treatment  of  stric- 
tures of  the  deep  urethra,  gradual,  continuous  and 
modified  rapid  dilation,  contraindications — internal 
urethrotomy — external  urethrotomy — external  ure- 
throtomy without  a  guide  (Gouley's,  Wheelhouse, 
Horwitz's,  Cock's,  and  Pederson's  methods),  retro- 
grade catheterization,  divulsion,  electrolysis,  urethrec- 
tomy,  retention  of  urine,  tappingof  the  bladder,  extrav- 
asation of  urine,  rupture  of  the  anterior  urethra,  rup- 
ture of  the  posterior  urethra,  urethral  fever   80-1 i6 

CHAPTER  V. 

Miscellaneous  Affections  of  the  Genito-urinary 
System:  Nocturnal  incontinence  of  urine:  Bacteriuria, 
haematuria,  hemorrhage  from  the  urethra.  Functional 
disorders:  Sterility,  operative  treatment,  spermator- 
rhoea, nocturnal  emissions,  sexual  impotence,  atonic, 
psychical,  symptomatic  and  organic  varieties    ....    11 7-130 

CHAPTER  VI. 

Diseases  of  the  Seminal  Vesicles:  Anatomy  of  tfie 
seminal  vesicles,  acute  seminal  vesiculitis,  chronic 
seminal  vesiculitis,  atonic  vesiculitis,  vasotomy,  tuber- 
culous vesiculitis 131-137 

CHAPTER  VH. 

Affections  of  the  Testis  and  its  Appendages  and 
Coverings:  Their  surgical  anatomy.  Affections  of 
the  scrotum:  Wounds,  contusions,  dermatoses, 
oedema,  elephantiasis,  tumors  and  gangrene.  Hydro- 
cele, congenital  and  acquired — the  Doyen,  Von  Berg- 


XVI  CONTENTS. 

man  and  Volkman  operations — encysted  hydrocele  of 
the  epididymis,  hydrocele  of  the  spermatic  cord — 
strangulation  of  the  testis  and  epididymis  from  torsion 
of  the  cord,  haematocele  of  the  tunica  vaginalis,  epidid- 
ymis, testis  and  cord,  atrophy,  tuberculosis — sarcoma, 
carcinoma,  castration — undescended  testicle — orchid- 
opexy^ — varicocele 138-152 

CHAPTER  VIII. 

Affections  of  the  Prostate  Gland  :  Surgical  anatomy, 
acute  prostatitis — abscess,  chronic  prostatitis,  prostat- 
orrhoea — hypertrophy  of  the  prostate,  changes  in  the 
urethra,  symptoms,  complications,  diagnosis  and 
treatment,  catheter  life — operative  treatment,  per- 
ineal and  urethral  prostatotomy,  perineal  and  supra- 
pubic prostatectomy,  Freyer's  operation,  Bottini's 
operation — treatment  of  retention  of  urine  from  hyper- 
trophy of  the  prostate — tuberculosis,  prostatic  calculi, 
malignant  growths,  Young's  operation I53~i77 

CHAPTER  IX. 

Surgical  Affections  of  the  Kidney:  Surgical  anatomy, 
perinephritis,  pyonephrosis,  hydronephrosis,  renal 
calculij  tumors,  cysts — floating  or  movable  kidney, 
traumatisms,  suppurative  affections,  pyelitis  and 
pyelonephritis,  renal  tuberculosis.  Operations  on  the 
kidney:  Nephrotomy,  nephrolithotomy,  nephrectomy, 
nephrorrhaphy,  renal  decapsulation 178-193 

CHAPTER  X. 

Affections  of  the  Bladder:  Cystitis,  vesical  calculus — 
litholapaxy — perineal  lithotomy,  suprapubic  cystot- 
omy, tumors  of  the  bladder,  exstrophy — traumatisms, 
rupture  of  the  bladder,  foreign  bodies  and  tuberculosis 
of  the  bladder 194-210 


CONTENTS.  XVll 

CHAPTER  XI. 

Affections  of  the  Ureters:  Anomalies,  traumatism, 

ureteritis,  stone  in  the  ureter 21 1-2 12 

CHAPTER  XII. 

Newer  Aids  to  Diagnosis:  Use  of  endoscope,  cryoscopy, 
X-ray,  cystoscopy  and  ureteral  catherization — sound- 
ing of  the  ureters,  lavage,  methylene  blue,  indigo 
carmin,  phenolsulphonephthalein,  and  phloridzin 
tests,  urine  segregator 213-229 

CHAPTER  XIII. 

The  Chancroid:  Synonyms,  definition,  mode  of  infection, 
bacteriology — site,  varieties,  complications,  period  of 
incubation,  duration  and  diagnosis — table  of  differ- 
ential diagnosis  of  chancroid  and  chancre — chan- 
croidal bubo — differential  diagnosis  of  syphilitic  and 
chancroidal  bubo — treatment  of  bubo — abortive  and 
radical — treatment  of  chancroid 230-237 

CHAPTER  XIV. 

Syphilis:  Synonyms,  definition,  general  considerations, 
immunity,  etiology,  description  of  the  spirochaeta 
pallida,  method  of  staining — the  dark  ground  illumin- 
ator— preparation  of  the  specimen  method  of  obtaining 
the  material — cultivation  of  the  spirochaeta  pallida, 
changes  of  the  blood,  prognosis.  Acquired  syphilis, 
primary  stage — vehicles  of  infection,  modes  of  infec- 
tion         /.......    231-246 

CHAPTER  XV. 

Primary  Syphilis:  Chancre— synonyms,  period  of  incu- 
bation— site,  duration — diagnosis,  character  of  indura- 


XVm  CONTENTS. 

tion,  differential  diagnosis  of  epithelioma  and  chancre 
— varieties  of  initial  lesion — chancre  of  urethra,  finger, 
tongue,  and  tonsils.  Termination  and  complications. 
Treatment.  Secondary  Syphilis:  General  considera- 
tion, symptoms — syphilis  of  the  lymphatic  glands,  of 
the  skin,  distinguishing  features  and  characteristics  of 
the  syphiloderm. — Classification  of  skin  eruptions, 
periods  of  syphilides  (table) — syphilis  of  the  mucous 
membranes,  of  the  mouth  and  tongue,  larynx,  hair, 
nails,  eyes  and  its  appendages,  affections  of  the  ear. 
Tertiary  Syphilis:  Affections  of  the  mucous  mem- 
branes, eyelids,  periosteum  and  bones,  gummata, 
tubercular  syphilides,  bullous  syphilides,  rupia,  serpig- 
inous syphilide — sclerosis  of  the  tongue,  gumma  of  soft 
palate  and  pharynx,  larynx,  oesophagus,  bronchi  and 
lungs,  spleen,  stomach  and  intestines,  rectum,  anus, 
muscles,  bursas,  loins,  fingers  and  toes,  epididymis  and 
testis,  blood-vessels,  nervous  system,  cerebral  syphilis. 
Syphilis  of  the  cord,  and  meninges,  locomotor  ataxia, 
cerebral  tumors,  malignant  syphilis  and  syphilopho- 
bia.  Hereditary  Syphilis:  Synonyms — duration — 
symptoms,  source  of  infection — CoUe's  law,  Profeta's 
law.  Retarded  syphilis,  affections  of  the  mucous 
membranes,  of  the  teeth — treatment  of  hereditary 
syphilis — prophylaxis — (Question  of  syphilis  and  mar- 
riage— treatment  of  acquired  syphilis — mercurial 
salivation,  its  causes,  symptoms  and  treatment,  ad- 
ministration of  mercury  by  the  mouth,  inunctions, 
hypodermic  injections,  use  of  sodium  and  mercury 
cacodylate,  thermal  baths,  ptyalism,  iodism,  serum 
diagnosis  of  syphilis — the  Wassermann  test,  Porges 
and  Meier's  simplified  method,  Klausner's  method, 
influence  of  treatment  upon  the  Wassermann  reaction, 
Noguchi's  butyric  acid  test,  the  Salvarsan  treatment  of 
Syphilis,  description  of  the  drug — intramuscular  injec- 


CONTENTS.  XIX 

tions,  intravenous  injections,  its  elimination,  mortality, 
contraindications,  therapeutic  effects,  value  in  loco- 
motor ataxia,  the  Herxheimer  reaction,  permanency  of 
the  effects  of  Salvarsan,  comparison  with  mercury, 
influence  of  on  the  Wassermann  reaction,  general 
untoward  effects 246-332 

List  of  Selected  Formula 333~34i 

List  of  Genito-urinary  Instruments  Required  for 

Office  Use 341-342 

List  of  One  Hundred  Questions 342-345 


COMPEND  OF 

GENITO-URINARY  DISEASES 

AND  SYPHILIS. 


CHAPTER  I. 

EXAMINATION  OF  THE  URINE. 

General  Technic. — ^A  specimen  of  urine  submitted  for  exam- 
ination should  be  taken  from  the  total  amount  passed  in  24  hours, 
which  is  collected  in  a  perfectly  clean  vessel.  When  a  quantitative 
examination  is  to  be  made,  a  specimen  from  the  24  hours'  quantity 
should  be  taken;  for  a  qualitative  examination  this  is  not  necessary; 
a  specimen  taken  late  in  the  afternoon  is  sufficient.  Do  not  base 
a  diagnosis  on  the  result  of  examining  a  specimen  from  "first 
in  the  morning" — sugar, .albumin,  and  indican  are  apt  to  be  absent 
from  the  first  in  the  morning  urine.  Information  should  be  elicited 
from  the  patient  as  to  amount  and  kinds  of  food  eaten,  also  of 
liquids  drunk,  and  the  amount  of  exercise  taken  just  prior  to  and 
during  the  collection  of  the  urine,  and  also  what  drugs  have  been 
taken  as  medicine.  In  life  insurance  examinations  the  physician 
should  satisfy  himself  that  the  specimen  of  urine  presented  is  that 
of  the  applicant.  Should  it  be  inconvenient  to  test  the  urine  as 
soon  as  it  is  received,  and  it  becomes  necessary  to  defer  the  exam- 
ination for  several  days,  or  the  specimen  is  sent  to  distant  parts,  a 
preservative  may  be  added  to  the  urine  which  will  prevent  decom- 
position, and  at  the  same  time,  not  interfere  with  the  ordinary  tests. 

I 


2  EXAMINATION    OF    THE    URINE. 

Thymol  is  excellent  for  this  purpose.  About  a  grain  of  the  crystals 
to  the  ounce  of  urine  is  sufficient.  Chloroform  and  boric  acid  are 
also  efficient  preservative  agents.  Preservative  should  not  be  added 
to  urine  when  it  can  be  avoided;  examination  should  not  be  de- 
ferred; a  clear,  yellow  acid  urine  will  keep  for  some  days  without 
preservative,  if  put  in  a  cool  place.  .  But  a  urine  cloudy  with  bac- 
teria, or  a  dilute  or  alkaline  urine,  will  spoil  quickly. 

URINARY  TESTS. 

Reaction. — The  reaction  of  the  urine  is  determined  by  the  use 
of  litmus  test  paper.  To  apply  the  test,  take  a  slip  of  the  red  and 
dip  one  end  of  it  into  the  urine.  The  moistened  paper  will  be 
colored  blue  if  the  urine  be  alkaline.  If  no  change  is  noticed  in  the 
color  of  the  dampened  paper,  use  a  strip  of  the  blue  in  the  same 
manner  and  if  the  urine  is  acid  the  dampened  part  will  be  changed 
to  RED.  If  no  change  in  color  is  effected  in  either  instance,  the 
urine  is  neutral. 

The  normal  reaction  of  the  urine  is  slightly  acid,  due  to  the 
presence  of  sodium  acid  phosphate.  The  change  to  alkaline  reaction, 
when  kept  standing,  is  a  kind  of  fermentation  produced  by  the 
action  of  bacteria,  the  micrococcus  urce  being  the  principal  one.  In 
this  fermentation,  the  urea  is  decomposed  into  ammonium  carbon- 
ate, giving  it  the  peculiarly  putrid,  ammoniacal  odor.  This  is  not 
a  pathogenic  change  when  taking  place  outside  the  body,  but 
occurs  in  all  urines. 

Amount. — Normally;  40  to  50  ounces  in  24  hours,  which  is 
increased  by  ingestion  of  large  quantities  of  liquids,  and  by  chilling 
of  the  skin,  whereby  perspiration  is  diminished.  Therefore, 
usually  larger  amounts  are  passed  in  winter  than  in  summer. 

Decreased-normally. — In  hypersecretion  of  the  skin;  and  by 
small  amount  of  liquids  taken. 

Increased-abnormally. — In  diabetes  insipidus  and  diabetes 
mellitus;  in  hysteria;  and  convulsive  conditions;  in  cardiac  hyper- 
trophy; cirrhotic  or  amyloid  kidney  and  pyelitis. 


URINARY   TESTS.  3 

Decreased. — In  renal  congestion,  acute  and  chronic  paren- 
chymatous nephritis,  acute  febrile  diseases,  early  stage  of  dropsy, 
and  in  diarrhoea. 

A  piece  of  red  litmus,  and  a  piece  of  blue  litmus  should  be  added 
at  the  same  time  and  allowed  to  remain  in  the  urine  three  minutes. 
Both  blue — alkaline;  both  red — acid;  no  change — neutral;  both 
change — amphoteric. 

While  urine  usually  becomes  alkaline  on  standing,  a  diabetic  urine 
will  become  more  highly  acid,  due  to  sugar  fermentation,  and  the 
formation  of  carbonic  acid  gas. 

Odor. — The  odor  of  normal  urine  is  characteristic,  and  may 
be  said  to  be  slightly  aromatic.  It  usually  varies  in  intensity  in 
direct  proportion  to  the  concentration  of  the  urine.  The  odor  is 
due  to  the  presence  of  volatile  acids.  Certain  foods,  e.g.,  cauli- 
flower, asparagus,  etc.,  alter  the  smell  of  the  urine;  so  do  various 
medicines,  such  as  turpentine,  cubebs,  copaiba,  and  sandalwood, 
the  presence  of  which  may  be  detected  by  the  odor.  In  cystitis, 
retention,  etc.,  it  has  the  ammoniacal  odor  which  is  often  fetid  in 
character.  When  the  urine  is  scanty  in  amount,  it  is  generally 
''strong." 

Color. — Altered  in  febrile  conditions;  haematuria;  jaundice. 
By  the  use  of  senna,  carbolic  acid,  logwood,  creosote,  rhubarb; 
santonin;  etc. 

Decreased. — In  excessive  elimination  of  water  by  the  kidneys, 
in  diabetes  mellitus,  diabetes  insipidus;  polyuria,  hysteria;  inter- 
stitial nephritis;  amyloid  kidney.  The  color  is  now  generally  con- 
ceded to  be  due  to  the  presence  of  urobilin.  The  intensity  of  the 
color  is  generally  dependent  upon  concentration.  The  more  urine 
excreted  the  lighter  the  color,  and  vice  versa. 

Active  perspiration,  food,  medicine,  and  pathological  processes, 
affect  the  color  more  or  less.  That  of  normal  urine  ranges  from 
pale  yellow  to  reddish-yellow.  Turpentine  makes  it  dark  and  gives 
it  the  odor  of  violets.  Blood,  if  the  latter  is  intimately  mixed  with 
the  urine  or  has  been  in  long  contact  with  it,  gives  the  urine  a  dull 
mucky  or  smoky  hue. 


4  EXAMINATION    OF   THE    URINE. 

Transparency  and  Consistency. — Normal  urine  is  transparent 
and  clear  when  freshly  voided.  On  standing  a  short  time  a  faint 
cloud  of  mucus  may  be  noticed  near  the  bottom.  Abnormally, 
urine  may  be  turbid  or  partially  opaque  from  the  presence  of 
precipitated  earthy  phosphates;  suspended  acid  urates;  and  the 
presence  of  pus  or  blood.  It  is  well  to  remember,  however,  that  a 
precipitate  of  phosphates  or  urates  is  not  necessarily  abnormal, 
that  phosphates  may  precipitate  in  alkaline  urine  and  urates  in  any 
concentrated  urine;  hence  the  cloudiness  or  opacity  under  these 
circumstances  is  not  indicative  of  pathological  causes. 

Specific  Gravity. — The  specific  gravity  of  normal  urine  is 
between  1015  and  1025.  That  of  urine  passed  by  infants  is  low 
— 1007  to  1012,  while  that  of  pathological  urine  may  vary  from 
looi  to  1050.  The  urine  of  Bright's  disease  and  diabetes  insip- 
idus is  usually  very  low,  but  that  of  diabetes  mellitus  is  high, 
though  in  exceptional  instances  may  be  quite  low — with  a  high 
percentage  of  sugar. 

The  specific  gravity  of  urine  is  taken  for  the  purpose  of  ascertain- 
ing the  relative  amount  of  solids  contained  therein,  and  is  easily 
and  rapidly  determined  by  the  use  of  the  "urinometer."  If  the  urine 
is  very  turbid,  the  sediment  should  be  allowed  to  settle,  or  must  be 
filtered.  If  the  amount  of  urine  is  small,  it  may  be  diluted  with 
one,  or  more  volumes  of  water,  carefully  measured,  and  the  specific 
gravity  of  this  solution  taken.  The  figure  as  read  from  the  urin- 
ometer  must  be  multiplied  by  the  number  of  volumes  of  water  used, 
plus  one.  For  example,  we  have  one-half  ounce  of  urine,  and  have 
to  dilute  it  to  two  ounces  to  get  the  specific  gravity,  which  is  found 
to  be  1006.  We  have  used  one  and  one-half  ounces  of  water  or 
three  volumes  of  water  to  one  of  urine.  Now  multiply  the  six  by 
the  number  of  volumes  of  water,  plus  one,  and  add  the  amount  to 
the  1000,  which  will  give  1024,  the  specific  gravity  desired. 

Average  Composition  of  Normal  Adult  Urine. — Urea  and 
the  CHLORIDES  are  the  chief  solid  constituents.  Therefore,  variations 
in  specific  gravity  of  normal  urine  are  chiefly  owing  to  variations 
in  these  constituents. 


URINARY   TESTS.  5 

Increased-normally:  by  excess  of  nitrogenous  food;  insufficient 
exercise  in  the  open  air;  and  diminished  oxidation. 

Increased-abnormally:  In  gout,  rheumatism,  hepatic  disease, 
acute  fevers,  insufficient  oxidation,  e.g.,  iri  diseases  attended  by 
dyspnoea,  in  anemia,  in  the  uric  acid  cachexia,  etc. 

Decreased:    In  chronic  Bright's  disease,  and  diabetes  mellitus. 

Urea. — Increased-normally:  By  excess  of  nitrogenous  food, 
and  exercise  in  the  open  air. 

Abnormally:  In  febrile  conditions  in  diabetes,  epileptic  attacks; 
by  the  ingestion  of  phosphorus,  arsenic,  and  alcohol. 

Decreased-normally:  During  fasting;  by  the  use  of  a  vegetable 
diet,  or  lack  of  proper  exercise. 

Abnormally:  In  diseases  of  the  liver,  acute  yellow  atrophy, 
carcinoma,  etc.;  faulty  excretion  due  to  renal  disorders;  gout; 
biliary  colic. 

Fowler's  Test. — To  one  volume  of  urine,  in  a  suitable  vessel, 
add  7  volumes  oi  Labarraque^ s  solution.  Decomposition  of  the  urea 
will  commence  at  once,  as  will  be  noticed  by  the  effervescence. 
Shake  the  vessel  occasionally  or  stir  with  a  clean  glass  rod  and  allow 
to  stand  for  two  hours,  at  the  end  of  which  time,  all  the  urea  will 
be  decomposed.  The  difference  in  the  specific  gravity  of  the  mix- 
ture before  and  after  decomposition  is  taken  and  multiplied  by  0.77 
which  shows  the  per  cent,  of  urea,  or  roughly,  the  number  of  grains 
in  100  c.c.  and  from  this,  knowing  the  amount  of  urine  voided, 
calculate  the  amount  of  urea  passed  in  24  hours. 

Chlorides. — Increased-normally:  By  drinking  abundantly 
of  water;  increased  ingestion  of  common  table  salt. 

Abnormally:  In  the  first  few  days  after  the  crisis  of  acute  febrile 
disease. 

Decreased-normally:  During  repose. 

Phosphoric  acid  when  it  appears  in  the  urine  combined  with 
calcium  and  magnesium  forms  the  ^'earthy  phosphates ^^  and  with 
sodium  and  potassium  "alkaline  phosphates.^' 

Test. — Filter  first  if  necessary,  and  ascertain  the  reaction.  (If 
neutral  or  alkaline  add  a  drop  or  two  of  acetic  acid).     Fill  a  test 


6  EXAMINATION    OF    THE    URINE. 

tube  about  half  full  of  urine  and  add  a  few  drops  of  ammonia 
solution,  enough  to  make  the  urine  distinctly  alkaline  and  gently 
heat.     The  earthy  phosphates  will  be  precipitated. 

Alkaline  Phosphates. — Cloudy  urine  as  a  result  of  alkaline 
phosphates  will  clear  with  the  addition  of  a  few  drops  of  acetic  acid. 

Indican. — The  presence  of  indican  as  a  constituent  of  the  urine, 
is  indicative  of  some  impairment  of  the  function  of  the  upper  gastro- 
intestinal tract.  Any  factor,  preventing  absorption  of  the  products 
in  the  early  process  of  digestion,  will  cause  a  marked  increase  in  the 
amount  indican  in  the  urine. 

The  conditions  in  which  this  occurs  are:  Obstructive  diseases  of 
the  bowels  and  other  abdominal  viscera;  peritonitis;  cholera;  and 
cirrhosis  of  the  liver. 

Obermeyer's  Test. — The  reagent  is  composed  of  strong  hydro- 
chloric acid,  to  which  are  added  2  parts  per  1000  oi  ferric  chlorid, 
the  combination  forming  a  fuming  yellow  liquid  which  keeps 
indefinitely.  The  urine  should,  preferably,  be  decolorized  with  a 
small  amount  of  lead-acetate  solution,  as  its  pigments  prevent  the 
recognition  of  the  blue  color.  Equal  parts  of  urine  and  of  Ober- 
meyer's reagent  are  mixed  in  the  test-tube,  and  about  2  c.c.  of 
chloroform  becomes  blue  in  proportion  to  the  indican  present, 
increasing  on  standing.  Normal  urine  becomes  faint  blue,  while 
an  increase  of  indican  gives  a  deep  color. 

Gurber  uses  osmic  acid  instead  of  ferric  chlorid  in  testing  for 
indican.  A  reagent  glass  is  filled  one-third  full  of  urine  and  the 
glass  is  then  filled  with  a  concentrated  solution  of  hydrochloric  acid, 
and  two  or  three  drops  of  a  i  per  cent,  solution  of  osmic  acid  are 
added.  In  a  few  seconds  the  fluid  turns  violet  or  almost  pure  blue, 
according  to  the  proportion  of  indican. 

ABNORMAL  CONSTITUENTS. 

Albumin, — It  is  claimed  by  many  observers  that  the  presence  of 
albumin  in  the  urine  is  always  a  pathological  symptom,  while  others 
maintain   that  it  may  under   certain   conditions, — e.g.,   excessive 


ABNORMAL    CONSTITUENTS.  7 

ingestion  of  albuminous  foods,  eggs,  etc.,  excessive  exercise,  over 
stimulation  from  alcoholic  excesses — be  present  in  health,  in 
which  cases  it  is  always  transitory.  A  Ibuminous  urine  is  usually  of 
low  specific  gravity  (1002-1016). 

The  amount  passed  in  24  hours  varies  according  to  the  severity 
of  the  case.  The  percentage  varies  from  i-io  per  cent,  to  2  per 
cent. 

Probably  the  best  test  for  albumin  is  as  follows: 

To  about  an  ounce  of  urine,  add  five  drops  of  a  5  per  cent,  solu- 
tion of  calcium  chloride  and  five  drops  of  ammonia;  let  stand  five 
minutes  and  filter.  Half  fill  a  test-tube  with  the  filtrate,  add  two 
drams  of  a  saturated  solution  of  sodium  chloride  and  one  dram  of 
strong  acetic  acid.  Mix  and  boil  the  upper  half  of  the  fluid.  The 
very  minutest  trace  of  albumin  will  form  a  milky  turbidity,  that 
can  be  readily  compared  with  the  clear  fluid  below.  Nothing  ever 
found  in  urine  will  interfere  with  this  test. 

Heat  Test. — Filter  the  urine  if  it  is  turbid.  If  acid,  it  may  be 
simply  boiled  in  a  test-tube.  The  presence  of  albumin  will  be 
indicated  by  an  opalescence,  a  cloudiness,  or  a  precipitate,  due  to 
the  coagulation  of  the  albumin,  which  if  slight  may  be  best  seen  by 
holding  the  test-tube  against  a  black  ground  such  as  the  coat  sleeve. 
If  the  urine  is  alkaline  or  neutral  in  reaction,  a  drop  or  two  of  acetic 
acid  must  be  added  before  applying  the  test,  or  if  excessively  acid 
just  a  drop  or  two  of  some  alkali,  such  as  ammonia. 

Heat  and  Nitric  Acid  Test. — Place  in  a  test-tube  about  8  or 
lo  c.c.  of  urine  and  heat  to  boiling.  Then  add  lo  or  12  drops 
of  nitric  acid.  The  presence  of  a  small  amount  of  albumin  is 
shown  by  a  slight  diffuse  cloudiness,  a  larger  amount  by  a  more  or 
less  flaky  deposit. 

Copaiba  and  turpentine  in  the  urine  may  give  a  reaction  with  this 
test.  They  may  be  distinguished  by  being  dissolved  by  the  addition 
of  alcohol.  Unless  nitric  acid  is  added  in  the  heat  test,  the  pre- 
cipitation of  earthy  phosphates  may  simulate  the  reaction  of 
albumin. 

Quantitative  Test. — Esbach's  albuminometer   consists   of   a 


8  EXAMINATION    OF   THE    URINE. 

thick  graduated  test-tube  and  is  designed  for  the  easy  quantitative 
determination  of  albumin.  It  is  cheap  and  its  manipulation  is 
simple.     Directions  for  use  accompany  each  one. 

Glucose  (Grape  Sugar,  Dextrose,  Diabetic  Sugar). — The 
question  as  to  whether  glucose  ever  occurs  in  the  urine  of  healthy 
persons  is  still  unsettled,  but  the  consensus  of  opinion  seems  to 
favor  the  view  that  it  may  be  found  in  small  quantities  under  certain 
normal  conditions.  However,  when  sugar  is  persistently  present, 
in  the  urine  it  is  abnormal.  Glucose  may  be  found  in  the  urine  in 
small  quantities  after  excessive  ingestion  of  sugar.  In  diabetes 
mellitus,  constant  glycosuria  is  a  diagnostic  symptom.  The' urine 
in  this  disease  is  usually  Ught  in  color;  is  passed  in  large  quantities 
(polyuria)  from  5  to  40  pints  in  24  hours;  is  of  high  specific  gravity, 
1025  to  1045;  has  a  sweetish  odor;  and  rapidly  ferments  when  kept 
in  a  warm  place.  A  persistent  foam  readily  forms  on  shaking  the 
urine.  On  standing  a  while  the  surface  of  the  urine  usually  becomes 
covered  with  a  thin,  almost  imperceptible,  scum.  The  amount  of 
sugar  present  varies  from  i  to  30  ozs.,  in  24  hours'  urine.  Glucose 
has  been  observed  in  the  urine  of  other  pathological  conditions,  e.g., 
lesions  of  the  brain;  diseases  of  the  heart  and  lungs,  cholera;  after 
chloroform  narcosis,  etc. 

Feeling's  Test. — ^Fehling's  solution  used  in  this  test,  deteri- 
orates on  standing,  and  hence,  for  preserving,  it  is  best  made  in  two 
parts  and  kept  in  separate  bottles.  In  this  way  it  may  be  kept 
indefinitely. 

In  one  bottle  keep  the  following  (No.  i). 

Pure  copper  sulphate 17  32  gms. 

Distilled  water 250 .  00  c.c. 

In  another  bottle  (No.  2). 

Rochelle  salt 87  .  00  gms.     Fehling's 

Caustic  soda 25 .00  gms.     Alkaline 

Distilled  water 250.00  c.c.        Solution 

To  apply  this  test,  mix  in  a  test-tube  equal  volumes  of  No.  i  and 
2,  dilute  with  equal  quantity  of  water"  and  boil.  No  precipitate 
should  be  noticed.     Now,  slowly  add  to  this  mixture  half  its  volume 


ABNORMAL    CONSTITUENTS.  9 

of  urine  and  again  boil.  The  presence  of  glucose  will  be  indicated 
by  an  orange  or  red-colored  precipitate.  The  earthy  phosphates  may 
be  thrown  down,  but  are  not  red  in  color. 

Biliary  Pigment. — Biliary  coloring  matters  occur  in  the  urine 
in  different  forms  of  icterus.  The  color  is  yellowish-brown,  deep 
brown,  greenish-yellow,  or  nearly  pure  green.  The  urine  foams 
easily  on  shaking,  and  the  foam  possesses  a  yellow  to  green  tint. 
The  sediment  usually  present  in  icteric  urine  also  partakes  of  the 
biliary  colors. 

Gmelins'  Test.  (Rosenbach's  modification). — ^Filter  the  urine. 
Apply  to  the  filter,  after  the  urine  has  passed  through,  a  drop  of 
nitric  acid.  A  pale  yellow^  spot  w^ill  be  formed,  surrounded  by  a 
play  of  colors, — red,  violet,  blue,  and  green. 

Heller's  Test. — ^Pour  in  a  test-tube  half  an  inch  of  pure  hydro- 
chloric acid  and  mix  enough  urine  with  the  acid  to  discolor  it,  then 
carefully  pour  nitric  acid  down  the  sides  of  the  test-tube  so  as  to 
form  a  layer  underneath.  A  beautiful  play  of  colors  takes  place  at 
the  union  of  the  two  liquids. 

Urinary  Sediments. — Normal  urine  when  voided  is  perfectly 
clear,  but  after  standing  a  few  hours,  a  light  cloud  of  mucus  may  be 
seen  floating  near  the  bottom.  The  urine  undergoes  acid  fermenta- 
tion which  is  observed,  if  the  urine  is  exposed  to  a  low  temperature. 
A  reddish-yellow  precipitate  of  amorphous  urates  ^^  brick-dust 
deposit  will  form.  At  a  warmer  temperature  and  at  the  climax  of 
acidity  of  the  urine,  the  urates  may  become  decomposed  and  uric 
acid  precipitated.  Following  the  acid  fermentation  the  urine  later 
gradually  becomes  alkaline. 

The  sediment  of  abnormal  urine  is  evident  by  the  turbidity  of 
the  urine  when  passed,  or  its  becoming  so,  and  exhibiting  a  precipi- 
tate shortly  thereafter. 

The  identification  of  organized  substances,  e.g.,  mucus,  blood, 
pus,  and /a/,  by  chemical  means  is  very  unsatisfactory.   ■ 

Mucus. — If  there  is  a  distinct  but  translucent  cloud  suspended 
near  the  bottom  of  the  urine  after  standing,  and  after  some  of  the 
supernatant  urine  has  been  carefully  removed,  the  remainder  is 


lO  EXAMINATION    OF   THE    URINE. 

slimy,  an  excess  of  mucus  is  indicated.  Large  quantities  of  mucus 
are  usually  accompanied  by  pus.  The  absence  of  albumin,  a  con- 
stituent of  pus,  but  not  of  mucus,  will  prove  the  absence  of  pus. 

Pus. — Pus  in  the  urine  (pyuria)  is  generally  due  to  some  acute 
or  chronic  inflammatory  process  present  in  the  urinary  tract,  such 
as  pyelitis,  renal  abscesses,  cystitis,  prostatitis,  urethritis  (gonor- 
rhoeal  or  simple),  and  genito-urinary  tuberculosis,  or  it  may  come 
from  some  extraneous  source,  as  the  discharge  into  the  urinary 
canal  of  the  peri-nephritic,  pelvic  or  other  origin,  or  from  the  burst- 
ing of  a  vulvo-vaginal  abscess.  Cancer  of  the  bladder  or  other 
urinary  organs  is  also  a  frequent  source  of  pyuria.  It  is  essential 
to  a  correct  diagnosis  that  the  source  of  the  pus  be  ascertained. 
Some  indications  that  point  to  the  source: — If  in  micturition,  the 
pus  passed  in  the  beginning  of  the  act  is  more  abundant  than 
toward  the  termination,  the  pus  comes  from  the  urethra,  if  more 
abundant  toward  the  end  of  micturition,  from  the  bladder.  Urine 
containing  pus  from  the  kidney  or  urethra  is  usually  acid  in  reac- 
tion, while  that  containing  pus  from  the  bladder  is  usually  alkaline 
and  is  often  accompanied  by  a  large  quantity  of  mucus.  If  blood 
be  present  it  will  be  intimately  mixed  with  the  pus,  while  if  of 
renal  origin,  the  blood  usually  lies  on  top  of  the  pus. 

In  prostatitis,  the  urine  often  contains  pus,  appearing  in  the  form 
of  threads,  very  similar  to  "tripper-fdden.^^ 

Urine  containing  pus  is  always  turbid  on  being  voided,  but,  after 
standing  for  some  time  in  a  vessel  the  pus  sinks  to  the  bottom,  and 
in  alkaline  urine  is  tenacious  and  slimy.  This  sediment  varies  in 
color  from  yellowish-white  to  greenish-white  and  is  opaque.  The 
only  positive  method  of  determining  the  presence  of  pus  in  the  urine 
is  by  means  of  the  centrifuge  and  microscope. 

Blood. — The  urine  may  contain  blood  (hematuria)  as  a  result 
of  hemorrhage  in  the  urethra,  at  the  neck  of  the  bladder;  in  the 
ureters;  the  pelvis;  or  substance  of  the  kidney;  or  it  may  gain  entrance 
to  the  urine  from  external  sources. 

If  the  blood  comes  from  the  urethra  it  is  generally  due  to  gonor- 
rhcea  or  stricture,  and  if  it  comes  from  the  anterior  part  it  escapes 


ABNORMAL   CONSTITUENTS.  IT 

by  compressing  the  urethra.  This  blood  is  bright  red  in  color. 
If  derived  from  the  prostatic  urethra,  it  appears  during  urination. 
The  introduction  of  instruments,  and  forced  or  excessive  coitus 
may  cause  urethral  hemorrhages.  The  color  of  the  blood  con- 
tained in  the  urine  is  of  significance  in  the  determination  of  its 
source.  Blood  on  long  contact  with  urine  becomes  dark  on  account 
of  oxidation,  so  in  renal  hemorrhage,  where  the  urine  is  intimately 
mixed  with  the  blood  and  where  the  contact  is  more  or  less  pro- 
longed, we  find  the  blood  of  a  dark  red,  reddish-brown,  brown  or 
dark  brown  color.  Albumin  which  is  a  constituent  of  blood  is  also 
present  in  hematuria. 

Test. — The  microscopic  and  spectroscopic  tests  are  the  most 
satisfactory. 

Casts. — The  exudate  from  the  kidney  tubules,  molded  to  the 
form  of  the  lumen  of  the  tube,  are  often  seen  in  the  urine  under 
certain  conditions: — They  consist  largely  of  hyaline  material  and 
are  colorless  and  transparent.  Very  frequently,  however,  they  may 
be  observed  as  waxy  or  opaque  bodies,  with  or  without  other  ele- 
ments. Should  these  contain  extraneous  bodies,  they  are  designated 
accordingly.     The  usual  forms  of  casts  are: 

Pure  hyaline;  Waxy; 

Epithelial   (with    epithelium   ad-  Blood  (casts  with  adherent  blood 

herent  thereto) ;  corpuscles) ; 

Fine  or  coarsely  granular;  Fatty   (adherent  fat  globules) ; 

Brown    granular     (stained    with  Fibrinous  (hyaHne  non-granular, 

blood  pigment) ;  pigmented  cast) . 

Casts  vary  in  size,  are  cylindrical  in  shape,  and  may  be  easily 
recognized. 

The  presence  of  casts  means  renal  congestion  which  may  be 
temporary  or  permanent.  Hyaline  casts  are  significant  of  pas- 
sive renal  congestion  or  chronic  affection.  The  granular  casts 
may  be  found  in  renal  diseases  but  may  appear  during  convalescence 
of  acute  nephritis.  Blood  casts  are  frequently  associated  with 
nephritis  due  to  traumatism  either  internally  {calculus),  or  externally. 
The  FATTY  casts  are  found  in  the  chronic  parenchymatous  forms  of 


12  EXAMINATION    OF    THE    URINE. 

nephritis.     The  waxy  casts  are  found  in  far  advanced  renal  dis- 
eases and  especially  in  amyloid  kidney. 

Epithelia. — The  presence  of  epithelia  in  the  urine  is  very  sig- 
nificant and  always  of  great  diagnostic  importance,  when  their 
characteristics  in  different  parts  of  the  tract  are  understood.  The 
coarser  cells  are  in  the  anterior  urethra  and  become  finer  and  more 
delicate  as  they  approach  the  kidney.  Epithelial  cells  also  vary  in 
their  properties  in  the  different  layers  of  the  same  mucous  mem- 
brane. The  outer  layers  contain  the  coarser  cells  and  the  deeper 
layers,  the  Jiner.  Epithelium  from  the  tubules  of  the  kidney  are 
round  and  smaller  than  those  from  the  pyramids.  They  contain 
large  nuclei  which  distinguishes  them  from  the  pus  cells.  Chronic 
inflammation  of  the  pelvis  of  the  kidneys  (chronic  pyelitis)  gives  off 

small  round  epithelial  cells  which  may  be 
distinguished  by  the  co-existence  of  blood 
and  pus  in  the  urine.  Epithelium  from 
the  ureters  is  rarely  found,  but  may  occur 
as  the  result  of  a  passing  calculus.  These 
cells  are  spindle  shape.  Cells  from  the  blad- 
der are  two  or  three  times  as  large  as  other 
cells  and  irregular  in  outline. 

Prostatic  secretion  is  recognized  float- 

FiG.  I. -Hum  AN  Sperm  a-      -         -^  ^^^  ^^^         ^^-        ^^  ^  ^^^j  j-    v  ^ 

TOZOA.      I.  Surface  View.     2.  *->  '  o  j  o 

Side  view.    3.  Looped  sem-     color  and  Stringy  in  appearance.     Usually 

inal     filament.      4.    Sperma-      ^^^^j^^    ^^^^    ^^^^^^  eXCCSSCS  and  prOStatic 
tozoan  of  an    ox:     a,  head;  ^ 

b,    middle    piece;    c,   tail,     congestion.     Should  pus  collcct  it  is  signi- 
'^  ^^^  ficant  of  a  gonorrhoeal  prostitis. 

Testicular  and  seminal  vesicular  secretions  do  not  appear  in 

the  urine  unless  together,  hence  in  the  presence  of  the  spermatozoa 

they  may  be  recognized.     (Fig.  i.)     They  are  usually  indicative  of 

spermatorrhoea  and  seminal  vesiculitis. 

Pseudomembranes  sometimes  appear  in  the  urine  and  are  easily 

recognized.     They  are  in  most  cases  from  a  new  growth  somewhere 

in  the  genito-urinary  tract,  and  are  also  commonly  found  in  certain 

forms  of  cystitis. 


ABNORMAL   CONSTITUENTS.  1 3 

Filaria  sanguinis  hominis  and  echinococcus  cysts  are  occa- 
sionally found  in  the  urine,  but  are  very  rare. 

Bacteria. — The  forms  of  bacteria  most  commonly  present  in  the 
urine  are  the  bacillus  coli  communis,  bacillus  tuberculosis,  and  the 
gonococcus. 

Technic  in  Examining  for  Tubercle  Bacilli  in  the  Urine. — 
The  specimen  should  be  centrifuged,  the  sediment  removed  by  a 
pipette,  and  placed  on  a  slide,  which  is  immersed  for  lo  minutes  in 
a  solution  of: 

Fuchsin i  gm. 

Alcohol  95  per  cent lo  gm. 

Carbolic  acid  95  per  cent 5  gm. 

Distilled  water 100  gm. 

Then  thoroughly  wash,  dry  with  blotting  paper  and  immerse  in 

Methylene  blue 2  gm. 

Sulphuric  acid 25  gm. 

Distilled  water 100  gm. 

Until  sufficiently  blue,  then  dry  and  mount,  examine  with 
I— 12  oil  immersion  lens.  Tubercular  bacillus  is  red  and  all  else 
will  be  found  blue. 

Weichselbaum's  method  of  staining  tubercle  bacilli  is  a  slight 
modification  of  the  above  and  is  especially  adaptable  in  distinguish- 
ing it  from  the  smegma  bacillus  which  stains  in  a  similar  manner 
with  the  fuchsin.  In  this  method  it  is  decolorized  with  absolute  alco- 
hol and  counterstained  with  an  aqueous  solution  of  methylene  blue 

The  smegma  bacillus  is  an  acid-fast  organism,  which  may  lead 
to  the  gravest  mistake  in  the  diagnosis  of  genito-urinary  tuberculosis. 
This  organism  was  first  discovered  as  a  result  of  the  investigations 
which  followed  the  announcement  by  Lustgarten  of  his  discovery 
of  the  cause  of  syphilis.  Whether  or  not  the  Lustgarten  bacillus 
and  the  smegma  bacillus  are  identical,  is  still  more  or  less  a  matter 
shrouded  in  mystery,  though  it  seems  likely  that  the  organisms  are 
the  same.  With  the  ordinary  methods  of  staining  it  resembles  the 
tubercle  bacillus.  Of  especial  importance  is  the  fact  that  the 
smegma  bacillus  is  found,  often  in  large  numbers,  beneath  the 


14  EXAMINATION    OF    TNE    URINE. 

prepuce  in  the  male,  and  about  the  vulva  and  clitoris  in  the  female, 
and  that  from  these  places  it  can  gain  entrance  into  the  urine  and 
thus  be  mistaken  for  the  tubercle  bacillus. 

The  smegma  bacillus  can  be  differentiated  from  the  tubercle 
bacillus  both  morphologically  and  by  its  staining  reactions.  In  the 
majority  of  cases  an  experienced  bacteriologist  can  probably  differ- 
entiate between  the  two  organisms,  but  there  are  cases  in  which 
such  differentiation  is  impossible  except  by  animal  inoculation, 
and  even  this  occasionally  fails. 

Ehrlich's  Diazo  Reaction. — The  diazo  reaction  as  a  urinary 
test  is  of  great  diagnostic  value  in  typhoid  fever  and  tuberculosis. 
The  diazosulphbenzol  must  be  freshly  formed.  To  obtain  it  in 
this  state  it  is  convenient  to  keep  two  separate  solutions: 

Solution  No.   i. 

Sulphanilic  Acid i  gm. 

Hydrochloric  Acid ;  .  .     25  c.c. 

Distilled  water 500  c.c.     Mix. 

Solution  No.  2. 

Sodium  Nitrate 0,5  gm. 

Distilled  water 500 .  o  c.c.     Mix. 

To  perform  the  test  mix  well  50  parts  of  solution  No.  i  (say  to 
50  c.c.)  and  i  part  (i  c.c.)  of  solution  No.  2.  Take  equal  parts  of 
this  mixture  and  of  urine  in  a  test-tube  and  add  stronger  water  of 
ammonia  until  the  alkaline  reaction  is  very  strong.  In  those  cases 
in  which  the  reaction  is  positive  the  solution  assumes  a  carmine-red 
color,  which  on  shaking  must  also  be  visible  in  the  foam.  If  the  test 
is  allowed  to  stand  24  hours  a  greenish  precipitate  is  formed.  The 
earthy  phosphates  are  precipitated  by  the  addition  of  the  ammonia. 

Fat,  contained  in  the  urine  (lipuria),  may  be  detected  by  the 
following  method: — The  turbid  urine  is  thoroughly  shaken  in  a 
test-tube,  and  an  equal  volume  of  ether  added.  Shake,  cork,  and 
set  aside  to  settle.  Carefully  pour  off  the  ethereal  solution,  which 
floats  on  top,  into  an  evaporating  dish  or  beaker,  and  set  aside, 
allowing  the  ether  to  evaporate.     The  residue  will  show  whether 


URINARY   CALCULI.  1 5 

fat  or  oil  matter  is  present.     Fat  thus  demonstrated  in  a  milky, 
opaque  urine  is  usually  indicative  of  chyluria. 

URINARY  CALCULI. 

If  the  calculus  originates  and  develops  in  undecomposed  urine 
it  is  said  to  be  primary;  if,  on  the  contrary,  the  calculus  is  a  product 
formed  by  urine  which  has  undergone  ammoniacal  decomposition, 
it  is  said  to  be  secondary.  If  the  calculus  is  composed  of  one  con- 
stituent only  it  is  a  simple  calculus;  of  two  or  more  ingredients  it 
is  a  COMPOUND  or  mixed  calculus. 

Composition. — They  are  most  commonly  composed  of  uric  acid, 
urated  calcium  oxalate,  "mulberry  calculus,"  mixed  calcium  and 
triple  phosphates,  calcium  phosphates,  calcium  carbonate,  xanthin, 
urostealith  ''fatty  calculus,"  singly  or  a  combination  of  two  or  more 
of  these. 

Genepal  Chaeacteristics. — Urinary  calculi  are  usually  com- 
posed of  two  or  more  substances  arranged  in  separate  and  alternate 
layers,  which  may  be  seen  by  carefully  dividing  the  calculus  through 
its  center  with  a  small  saw.  (See  Chapters  Renal  and  Vesical 
Calculi.) 

Uric  Acid  Calculi. — These  are  the  most  frequently  found 
(30  per  cent.)  of  all  calculi.  They  are  reddish  or  reddish-brown, 
usually  smooth,  but  may  be  irregular.  May  occur  in  any  size  up 
to  a  goose  egg,  and  vary  in  weight  from  5  milligrams  to  150  grams. 
They  are  hard,  but  not  so  hard  as  those  composed  of  calcium  oxa- 
late, are  of  round  or  oval  shape,  and  when  divided  usually  present 
a  stratified  appearance. 

Tests. — A  small  portion  of  the  calculus  burned  in  an  alcohol 
blaze  gives  off  the  odor  of  burnt  corn,  and  leaves  only  a  faint  trace 
of  ash  after  ignition.  A  portion  of  the  calculus  will  respond  to  the 
murexid  test.  Another  small  particle  will  dissolve  entirely  in  a 
drop  of  solution  of  caustic  potash  and  will  be  precipitated  by  an 
excess  of  acetic  acid. 
Uratic   Calculi. — These   are   composed   of   ammonium   urate. 


1 6  EXAMINATION    OF    THE    URINE. 

They  are  rare  and  are  found  usually  in  infants  and  children. 
They  are  dark  gray  or  whitish,  when  moist  are  pliable,  and  when 
dry  are  friable. 

Calcium  oxalate  (oxalate  of  lime)  calculi — are  next  to  the  fore- 
going most  frequently  found.  They  form  about  20  per  cent,  of  all 
calculi,  and  are  the  hardest  of  any.  They  occur  in  both  round  and 
oval  forms;  their  surface  is  rough  and  is  of  a  dark  gray,  dark  purple, 
or  dark  brown  color.  These  calculi  may  occur  in  the  form  of 
small,  rounded,  smooth  bodies,  which  are  known  as  "hempseed" 
calculi,  and  in  other  cases  assume  the  so-called  ''mulberry"  type. 
Calcium  oxalate  calculi  often  have  a  coating  of  phosphates. 

Test. — A  particle  of  the  calcium  oxalate  is  insoluble  in  acetic 
acid,  but  is  soluble  in  a  drop  of  hydrochloric  acid  with  effervescence 
when  heated.  Ammonia  solution  added  in  excess  will  precipitate 
the  calcium  oxalate. 

Mixed  Phosphate  Calculi. — The  most  common  forms  of  mixed 
phosphate  calculi  are  those  composed  of  a  mixture  of  calcium  phos- 
phate and  of  ammonio-magnesian  phosphate.  They  are  always 
a  product  of  the  ammoniacal  decomposition  o'f  the  urine  whereby 
the  earthy  phosphates  are  precipitated.  These  calculi  are  generally 
oval  shape,  are  chalky  in  appearance,  and  are  usually  friable. 
When  divided  in  half  the  interior  is  found  to  be  laminated,  and  here 
and  there  shiny  points  of  triple  phosphate  crystals  may  be  seen. 
These  calculi  frequently  attain  a  large  size. 

Test. — A  particle  of  this  concretion  will  readily  dissolve  in  a  drop 
of  hydrochloric  acid,  and  will  be  precipitated  by  adding  excess  of 
caustic  soda  solution. 

Calcium  Phosphate  Calculi. — These  are  rare.  They  have  a 
smooth  white  surface.  Their  laminae  are  easily  separated,  peeling 
off  like  crusts.  These  calculi  are  sometimes  found  in  the  prostate 
gland,  and  are  then  known  as  "prostatic  calculi." 

A  convenient  and  complete  record  may  be  obtained  by  the  use  of 
the  following  form: 


URINARY   CALCULI.  1 7 

URINALYSIS  RECORD. 


Date 

Name  of  Patient.  . . 

Address 

Suspected  Ailment. 


PHYSICAL  PROPERTIES. 

Amount  passed  in  24  hours Color {Vogel's  Scale.) 

Odor Reaction Sp.  gr 

Relative  quantity  of  sediment 

Physical  character  of  sediment 

Chemical  Examination. 

Normal  constituents 

Uricmcids  and  urates Chlorides  (Quantitative) 

Sulphates • f  Earthy . 

Phosphates  ■{ 
Urea [  Alkaline 


Abnormal  Constituents  in  Solution. 

^  Heat  Test 

Albumin   (Qual.)     ■{  Tanret's  Test 

[  Copper  Test 

,^      ,  .     f  Phenyl-hydrazin  Test 

Sugar  (Qual.)    [  p-^^i^^^, ,  j-^.^ 

Biliary  Matters 

Indican 

Composition  of  Sediment. 

Blood Pus Mucus Uric  acid . 

Microscopic. 


Casts 


I  Epithelial Finely  Granular. 

J  Narrow  hyaline Dark  Granular. . 

I  Medium  hyaline Bloody 

[  Broad  hyaline Amyloid 

^  r^  {  Cylindroids 

False   Casts     <   „      „  „ 

[  bmall  Kound 

.^^  r  Spindle  Form 

Epithelia      <   _  ^  „ 

[  Pavement  Form 

Pus Erythrocytes 

Uric  acid .  .  .  .  / Triple  Phosphates 

Amorphous  Urates Micro-organisms 

Remarks 

Conclusions 


CHAPTER  II. 

URETHRITIS. 

Urethritis  is  a  generic  term,  including  all  forms  of  inflammations 
of  the  urethra,  and  is  pre-eminently  a  disease  which  may  be  said  to 
flourish  among  the  younger  element  of  the  male  sex.  It  is  by  far 
the  most  frequent  affection  of  the  genito-urinary  tract,  and  is  very 
rarely  acquired  from  any  other  source  than  by  sexual  contact.  It 
is  highly  infectious  involving  particularly  the  mucous  membrane  of 
the  urethra.  The  most  common  term  for  this  condition  in  all  its 
phases  is  gonorrhcBa.  That  urethritis  is  not  merely  a  local  affec- 
tion will  be  seen  in  the  succeeding  chapters  in  which  the  complica- 
tions occurring  in  both  sexes  will  be  considered.  It  is  much  more 
common  in  males  than  in  females. 

The  first  attack  is  more  acute  in  its  symptoms  than  subsequent 
invasions.  The  symptoms  in  females  are  much  less  acute  than  in 
males.  The  most  frequent  exciting  cause  is  the  gonococcus,  but 
urethritis  may  occur  as  the  result  of  infection  from  other  micro- 
organisms. The  type  of  the  disease  in  which  the  gonococcus  is  a 
causative  factor  constitutes  the  specific  form,  whereas,  urethritis 
occurring  from  sources  other  than  the  specific  organism,  is  termed 
the  non-specific  variety. 

The  different  varieties  of  urethritis  have  been  classified  by 
Lydston,  as  follows: 


(a)  Simple 


Acute  and  chronic    . 


(b)  Specific 


Bacteria. 

Toxic. 

Chemical. 

Traumatic. 

Gonococcal. 

Chancroidal. 

Syphilitic. 


Predisposing: 


SIMPLE    URETHRITIS.  1 9 

The  ETiOLOGic  FACTORS  may  be  suramarized  as  follows: 

I   7.  Diathesis — gout  and  rheumatism. 

I   2.  Chronic  urethral  disease. 

3.  Morbid  state  of  urine. 

4.  Sexual  abuse. 

5.  Indiscretion — dietetic,  sexual. 

6.  Alcoholism. 

1.  Trauma. 

2.  Bacteria. 

3.  Toxic. 

4.  Chemic. 

5.  Sexual  excess  or  strain. 


Exciting  causes: 


.      SIMPLE  URETHRITIS. 

Synonyms. — Non-specific  and  non-infectious  urethritis. 

Any  of  the  causative  factors  enumerated  in  the  foregoing  classifi- 
cation, especially  gout  and  rheumatism  may  constitute  the  etiology 
of  a  simple  urethritis. 

Some  pre-existent  chronic  urethral  affection,  e.g.,  stricture  is  the 
usual  predisposing  cause.  This  condition  renders  the  urethra 
extremely  susceptible  to  the  effect  of  sexual  or  alcoholic  excesses. 
Therefore,  the  previous  venereal  history  should  always  be  borne  in 
mind,  in  considering  the  true  origin  of  non-specific  infections. 

SPECIFIC  URETHRITIS. 

Synonyms. — Infectious  urethritis,  gonorrhoea,  urethritis,  clap, 
blennorrhagia,  gleet. 

The  PERIOD  OP  INCUBATION  varies  from  twenty-four  hours  to  ten 
days  after  the  date  of  contagion,  with  an  average  of  two  to  five  days. 

Etiology. — The  predisposing  and  exciting  causes  are  practically 
the  same  as  those  enumerated  for  simple  urethritis;  but  the  most 
accepted  exciting  cause  is  the  gonococcus,  which  is,  without  a  doubt, 
the  definite  specific  micro-organism  of  gonorrhoea.  This  microbe 
was  discovered  by  Neisser  in  1879,  who  detected  it  in  the  pus  cor- 
puscles, by  various  processes  of  staining. 

There  are  certain  predisposing  factors,  however,  which  may  render 


20 


URETHRITIS. 


the  urethral  mucous  membrane  especially  liable  to  gonococcic 
invasion.  These  are:  a  large  meatus  (natural  or  acquired),  or  a 
condition  of  hypospadias.  The  size  of  the  glans  penis  may  also 
render  its  bearer  particularly  susceptible  to  infection. 

The  Gonococcus. — This  may  be  clearly  seen  with  a  1-12  inch 
oil  immersion  lens,  after  the  spread  has  been  stained  by  any  of  the 
various  methods.  Each  half  of  the  diplococcus  resembles  a, coffee- 
bean.  These  are  usually  found  in  colonies  of  ten  to  twenty,  or 
more,  and  lie  close  together  with  their  flattened  surfaces  almost 

in  apposition,  leaving  a  nar- 
row space  between  them,  with 
their  convex  margins  outward. 
(Fig.  2.) 

It  is  said  that  certain  diplo- 
cocci  normally  inhabit  the  ure- 
thra, therefore,  in  making  a 
positive  diagnosis  or  giving 
medico-legal  testimony,  the 
microscopic  examination  must 
be  supplemented  by  the  aid  of 
culture  tests.  The  gonococcus 
is  found  in  the  purulent  dis- 
charge of  acute  specific  urethritis,  in  the  threads  and  discharges 
of  some  cases  of  subacute  and  chronic  forms  of  urethritis,  in  the 
gonorrhoeal  secretions  from  the  vagina,  uterus,  conjunctiva,  and 
rectum;  and  sometimes  from  the  infected  mucous  membrane  of 
the  mouth,  nose,  and  skin.  In  many  of  the  complicating  conditions 
of  gonorrhoeal  urethritis,  e.g.,  endocarditis,  pleurisy,  and  peritonitis, 
gonococci  have  been  found  in  the  blood  of  such  infected  individuals. 
The  DISTINGUISHING  FEATURES  OF  THE  GONOCOCCI  according  to 
Neisser  are:  the  tendency  to  arrange  themselves  in  pairs,  which  are 
usually  found  in  colonies,  and  the  fact  that  they  are  either  extra- 
cellular or  intra-cellular  (outside  or  in  the  pus  corpuscle) . 

Technic  for  the  Examination  of  Gonorrhoeal  Discharge. — 
Spreads  are  made  on  cover  glasses  or  on  slides.     If  cover  glasses  are 


c     a 

Fig.  2. — Intra-cellular  (a.)  and  (b.,  c.) 
extra-cellular  gonococci.      (Casper.) 


SPECIFIC    URETHRITIS.  2  1 

used  a  drop  of  the  pus  is  placed  on  one  and  this  covered  by  a  second 
glass,  which  causes  the  pus  to  spread  out.  The  cover  slips  are  then 
drawn  apart,  the  film  of  the  discharge,  on  each,  is  then  dried  in  the 
air,  or  by  passing  it  over  a  bunsen  flame  several  times,  and  can  be 
examined  at  any  time. 

If  a  shde  is  used,  a  drop  of  the  discharge  is  placed  on  it  with  a 
small  cotton  swab  or  a  match  stick  and  smeared  lightly  in  one  direc- 
tion. This  latter  precaution  should  be  heeded  because  if  rubbed 
upon  the  slide,  great  distortion  of  the  cellular  elements  usually  takes 
place.  The  smear  is  then  dried  in  the  air  and  examined  in  the  same 
way  as  the  cover  slips. 

For  a  stain,  Loffier's  methylene  blue  is  absolutely  the  best.  The 
spread  is  fixed  by  passing  it  several  times  through  a  flame,  the  dye 
applied  for  3  to  5  seconds,  washed  off  with  water,  dried,  and  mounted 
in  balsam. 

This  will  suffice  for  any  specimen  supposed  to  contain  the  gono- 
coccus.  If,  however,  any  doubt  exists  as  to  the  bacteria  being 
gonococci,  or,  if  for  the  purpose  of  deciding  a  medico-legal  question, 
the  preparation  should  be  decolorized  by  Gram's  method  and  coun- 
terstained  with  a  weak  solution  (i-io)  fuchsin  or  Bismarck  brown. 
In  this  staining  process  the  gonococcus  will  be  stained  red. 

Technic  of  Gram's  Method. — The  stain  used  in  this  process  is 
an  aniline  gentian  violet  solution  made  as  follows:  Anilin  oil,  one 
part,  distilled  water,  twenty  parts,  shake  well.  Filter  through 
filter  paper  and  add  to  the  filtrate  the  saturated  alcoholic  solution 
of  gentian  violet,  in  the  proportion  of  one  part  to  ten  of  the  filtrate. 
This  solution  should  always  be  freshly  made.  After  the  spread  has 
been  stained  by  this  in  the  usual  manner,  it  should  be  immersed  in 
the  following  solution,  from  one  to  three  minutes. 

Iodine i  part 

Potassium  iodide 2  parts 

Water 3°°  P^rts 

Tablets  of  both  these  reagents  can  be  procured,  thus  making  it 
convenient  to  make  fresh  solutions  whenever  desired. 


2  2  URETHRITIS. 

Then  decolorize  with  absolute  alcohol  and  transfer  to  a  solution 
of: 

Bismarck  brown i  part 

Water 20  parts 

Stain  for  1/2  minute,  dry  and  mount  in  balsam  and  examine 
with  oil  immersion  lens. 

Pus  cells  will  be  found  light  brown  in  color,  and  the  gonococci 
will  be  shown  in  marked  contrast,  imbedded  in  the  cells.  In  dis- 
charges from  subacute  and  chronic  urethral  diseases,  a  new  method 
of  staining  has  been  suggested  by  Von  Wahl.  The  mixture  consists 
of  aurine  saturated  alcoholic  solution  15  c.c.  (i-io)  and  from  8  to 
10  c.c.  of  a  saturated  alcoholic  solution  of  thiolin  (1-20),  which  is 
shaken  and  30  c.c.  of  distilled  water  then  added.  1-50  of  an  aqueous 
solution  of  methylgreen  may  also  be  added  to  brighten  the  cellular 
elements.  The  nuclei  are  thus  stained  a  bluish  green  and  the  gono- 
cocci a  deep  violet  color. 

A  great  many  other  stains  have  been  advocated  for  the  staining 
of  the  gonococcus,  but  the  processes  just  given  should  prove  ade- 
quate for  all  purposes. 

Inoculation  upon  suitable  culture  media,,  should  also  be  made 
to  further  substantiate  the  diagnosis.  The  gonococcus  will  not 
develop  upon  ordinary  agar  or  bouillon. 

The  spreads  should  be  examined  with  a  1-12  inch  oil  immersion 
lens.  Quite  frequently  gonococci  will  be  seen  extra-cellular;  but  in 
the  majority  of  instances,  the  organism  is  found  in  the  pus  or  epi- 
thelial cells,  irrespective  of  the  origin  of  the  discharge,  whether  from 
urethra,  conjunctiva,  or  abscess. 

The  culture  media  in  which  gonococci  may  be  cultivated  are, 
blood  serum,  and  agar-agar,  and  urine  and  urea,  and  in  acid 
solutions. 

The  TOXINS  from  gonococci  may  also  produce  an  acute  urethritis, 
but  it  is  much  less  severe  in  its  course  and  symptoms  than  the  true 
specific  type. 


ACUTE   ANTERIOR    URETHRITIS.  23 

The  Infectiousness  of  Chronic  Urethral  Discharges. 

At  just  what  stage  the  gonococci  disappear  from  the  discharge  is 
always  most  indefinite,  hence  the  importance  of  conservatism  in 
giving  an  opinion  as  to  the  safety  of  the  individual  entering  into 
matrimony  within  any  certain  prescribed  time  after  the  date  of 
infection.  Pus  containing  gonococci  has  been  found  many  months 
after  having  been  presumably  cured.  Before  any  decision  is 
reached,  therefore,  even  in  dismissing  a  patient  as  being  permanently 
free  from  the  disease,  the  physician  should  carefully  examine  the 
first  morning  urine.  Should  pus  and  epithelial  cells  be  present,  and 
even  if  microscopic  examination  be  negative,  the  treatment  must  be 
continued.  Where  the  threads  persist  it  is  important  to  make 
repeated  examinations  of  the  secretions  from  the  seminal  vesicles 
and  prostate.  It  is  safe  to  say  from  the  conclusions  of  most  author- 
ities that,  after  an  interval  of  freedom  from  all  symptoms  for  about 
six  months  from  the  time  of  the  disappearance  of  the  infection,  the 
patient  may  be  considered  safe  to  marry. 

ACUTE  ANTERIOR  URETHRITIS. 

Period  of  Incubation. — Two  to  ten  days  after  exposure,  as  a 
rule,  the  infection  becomes  manifest.  Sometimes,  though  rarely, 
the  symptoms  begin  in  a  few  hours.  The  average  period,  however, 
is  about  three  days. 

Etiology. — Anterior  urethritis  may  be  due  to  several  causes,  but 
is  as  a  rule  the  result  of  pyogenic  organisms,  or  their  products,  being 
absorbed  at  the  point  of  an  abrasion  of  epithelial  covering  on  the 
mucous  membrane  of  the  anterior  urethra. 

Pathology. — When  bacteria  gain  entrance  to  the  urethra,  the 
pathological  changes  result  in  a  general  hyperemia,  swelling  and 
hypersecretion  of  the  mucous  membrane,  involving  principally  the 
epithelial  and  subepithelial  layers.  In  this  invasion  the  gonococci 
multiply  rapidly  and  penetrate  between  the  epithelial  cells  into  the 
protoplasm  substance  (observed  by  Bumm).  When  they  lodge 
in  the  epithelial  connective-tissue  layer,  they  are  antagonized. 

This  reaction  on  the  part  of  the  tissues  gives  rise  to  an  exudation, 


24  URETHRITIS. 

which  is  a  favorable  media  for  the  continued  multiplication  of  these 
organisms.  Their  further  incursion  is  hindered  at  this  stage,  how- 
ever, by  the  development  of  an  epithelial  covering.  In  the  acute 
invasion  the  secretion  is  serous,  later  becoming  purulent,  light 
yellow  in  color,  and  thick  and  creamy  in  character.  It  is  at  first 
scant,  but  now  comes  copiously.  In  the  stage  of  decline  the  dis- 
charge becomes  lighter  in  color,  more  mucoid  and  tenacious.  In 
the  substance  of  the  urine  which  will  be  found  quite  transparent, 
abundant  threads,  or  '^Tripper-faden,''  will  be  seen. 

Symptoms. — A  sense  of  itching  and  tingling  at  the  meatus  is 
first  noticed.  More  or  less  urethral  discharge  will  soon  appear. 
At  first  it  is  thin;  later  it  becomes  mucoid,  and  still  later  muco- 
purulent. The  patient  may  now  complain  of  ardor  urinae,  or  a 
feeling  of  scalding  on  urination.  Tenesmus  or  hesitancy  in  starting 
stream  may  or  may  not  be  present  in  this  train  of  symptoms.  The 
discharge  which  is  now  thick,  creamy,  and  copious  may  even 
assume  a  greenish  hue  and  sometimes  even  be  tinged  with  blood  or 
mucosaneous  pus,  as  it  is  often  leimed.  During  this  period  the 
patient  is  very  apt  to  suffer  from  attacks  of  chordee. 

The  next  effect  may  be  a  considerable  diminution  in  the  size  of 
the  stream  of  urine;  due  to  the  swollen  state  of  the  mucous  membrane 
of  the  urethra,  thus  lessening  the  caliber  of  the  canal,  and  often 
causing  a  complete  retention  of  urine.  The  urine  is  frequently 
discharged  in  two  or  more  streams,  or  is  forked,  in  consequence  of 
the  irregular  and  contracted  state  of  the  uretnra,  and  when  it  is 
voided  it  is  usually  attended  with  much  straining,  pain,  and  scalding. 

In  a  first  gonorrhoea  the  glands  of  the  groin  are  often  sympathet- 
ically affected,  and  become  more  or  less  enlarged  and  swollen,  tender 
and  often  painful. 

These  conditions  are  sometimes  attended  with  constitutional 
DISTURBANCES,  c.  g.,  fever,  restlessness,  and  mental  anxiety.  The 
pain  often  extends  up  along  the  cord  into  the  groins,  radiating  down 
the  thighs  and  perineum.  The  testicles  may  be  tender.  After  the 
first  ten  days  under  proper  care  and  attention,  the  inflammatory 
symptoms  will  usually  subside  and  the  discharge  will  diminish,  and 


ACUTE  ANTERIOR   URETHRITIS.  25 

be  much  thinner  and  watery  in  its  consistency.  This  ceases  alto- 
gether in  the  course  of  the  next  few  weeks  and  there  is  a  gradual 
return  to  normality,  as  regards  the  character  of  the  urine,  etc. 

The  mucoid  discharges  from  the  urethra  may  persist  indefinitely 
in  neglected  cases.  This  condition  is  commonly  known  as  gleet. 
(See  chap,  chronic  urethritis.) 

TREATMENT  OF  ACUTE  ANTERIOR  URETHRITIS. 

Prophylactic,  local,  and  constitutional  measures  are  to  be 
observed  in  the  treatment  of  urethritis. 

The  ABORTIVE  treatment;  is  sometimes  resorted  to  if  the  patient 
presents  himself  soon  after  the  date_of  infection,  while  the  symptoms 
are  still  in  abeyance  or  during  the  period  of  incubation.  This 
method,  however,  is  always  attended  with  great  pain,  therefore  the 
patients  should  be  warned  of  same,  told  of  the  uncertainty  of  its 
results,  and  then,  if  their  consent  is  obtained,  its  application  is  in 
some  instances  warranted.  The  method  is  as  follows:  The  patient 
should  first  pass  his  urine  and  the  anterior  urethra  then  be  irrigated 
with  a  mild  antiseptic  solution.  An  endoscope  is  now  passed  for  a 
distance  of  about  three  inches,  and  an  application  to  the  mucous 
membrane  at  the  end  of  the  tube  is  made  with  an  aqueous  solution 
of  nitrate  of  silver  (15  gr.  to  the  oz.),  along  its  entire  surface  from 
within  outward  as  the  instrument  is  being  withdrawn.  The  patient 
should  be  kept  in  bed  and  the  penis  covered  with  a  dressing  saturated 
with  a  solution  of  lead  water  and  laudanum  or  an  ice  bag  applied. 
This  procedure  is  generally  followed  by  intense  pain,  the  discharge 
becomes  very  copious  and  purulent,  and  the  ardor  urinae  is  intense. 
Should  success  crown  this  effort,  the  secretion  will  within  a  few  days 
become  serous  and  from  five  to  six  days  disappear  entirely. 

Treatment  of  the  Acute  Stage. — The  penis  should  first  be 
examined  for  any  anatomical  defects,  e.g.,  phimosis,  hypospadias, 
contracted  meatus,  any  of  which  may  complicate  the  treatment, 
and  must  therefore  be  treated  accordingly.  Should  any  of  these 
conditions  be  present,  such  deformity  must  of  necessity  be  corrected. 
The  patient  should  be  instructed  to  abstain  from  all  forms  of  exer- 


26  URETHRITIS. 

cise  and  even  to  rest  in  bed  if  possible.  Riding  a  bicycle,  horseback, 
etc.,  should  be  prohibited.  Patients  who  are  obliged  to  be  about 
should  be  ordered  to  wear  a  suspensory  bandage.  The  importance 
of  cleanliness  must  be  impressed  upon  him,  also  the  dangers  of 
infecting  the  eyes,  conveying  it  to  others,  etc.,  all  of  which  he  must 
be  told  may  be  avoided  by  simply  washing  the  hands  thoroughly  and 
keeping  the  parts  from  coming  in  contact  with  the  underclothing  as 
little  as  possible.  He  should  avoid  highly  seasoned  foods  and  con- 
diments. The  use  of  alcohol,  coffee,  and  carbonated  drinks  should 
be  interdicted.  Asparagus,  tomatoes,  fish,  and  oysters  should  also 
be  eschewed. 

Various  ingenious  dressings  have  been  devised  to  keep  the 
discharge  from  coming  in  contact  with  the  wearing  apparel.  A 
very  excellent  dressing  for  this  purpose  is  the  gonorrhoeal  bag  with 
tapes  attached  to  it,  encircling  the  body  and  arranged  so  that  the 
organ  is  free  from  all  constrictions  and  carried  in  a  perfectly  natural 
manner.  The  discharge  drains  into  a  wad  of  absorbent  cotton 
which  is  placed  in  the  bottom  of  the  bag.  The  patient  is  instructed 
to  change  this  cotton  frequently,  and  burn  it  as  soon  as  it  becomes 
soiled.  The  bowels  should  be  kept  active  and  near  to  normal  as 
possible,  the  urine  rendered  bland  by  the  patient  drinking  plenty 
of  water  and  mild  and  alkaline  diluents. 

Aside  from  the  general  outlines  formulated  in  the  regular  routine 
treatment  of  an  acute  urethritis,  cases  very  often  present  themselves 
in  which  departures  are  necessarily  made  therefrom  and  these  are 
treated  on  the  expectant  symptomatic  plan  of  treatment.  The 
additional  measures  that  have  already  been  suggested  are  applied 
as  the  exigencies  or  conditions  require. 

For  the  purpose  of  preventing  hyperacidity  of  the  urine  the  follow- 
ing prescription  is  used: 

]^      Soda  bicarbonatis 5  ss 

Tr.  hyocyami 5  ij 

Syr.  Zingiberus §  iij 

Aquae  q.  s.  ad 5  vj 

Sig.:     Tablespoonful  three  t'mes  a  day  after  meals.* 
*  See  list  of  formulas  at  end  of  volume. 


ACUTE  ANTERIOR    URETHRITIS.  27 

If  the  symptoms  are  very  acute,  and  attended  with  swelling  and 
oedema  of  the  glans,  immersion  of  the  penis  in  hot  boric  acid  solution 
is  an  excellent  measure  in  affording  relief. 

Attacks  of  chordee  may  be  prevented  by  prescribing  the  following : 

Ty      Sodii  bromidi. .' 5  iv 

Tr.  Zelladonnae itl  xxx 

Liq.  potassii 5  iv 

Syr.  Zingiberus f  o  iij 

Aquae  q.  s.  ad f  o  v j 

Sig.:     Tablespoonful  three  times  a  day  and  at  bed  time. 

During  the  height  of  the  acute  stage  it  may  be  necessary  to 
administer  some  anaphrodisiac  for  obvious  reasons.  An  excellent 
sedative,  therefore,  is: 

I^      Fl.  ext.  ergotae _. ^  xv 

Potassii  bromidi gr.  xx 

Tr.  hyoscyami  aa itl  ^^^ 

Syr.  aurantii  q.  s.  ad O  ss 

Sig.:     At  bed  time. 

In  cases  of  retention  of  urine  occurring  in  acute  gonorrhoea 
it  may  usually  be  relieved  by  the  patient  taking  a  hot  sitz  bath,  or 
applying  a  hot  water  bag  over  the  pubis,  the  patient  going  to  bed 
and  given  diaphoretics.  These  will  in  most  instances  relax  the 
spasm  and  allow  the  bladder  to  empty  itself. 

The  SPECIFIC  CONSTITUTIONAL  THERAPY  is  limited  principally  to 
the  balsamic  preparations,  which  are  probably  the  most  reliable 
adjuvant  that  can  be  given  in  the  treatment  of  gonorrhoea.  In  the 
beginning  it  is  best  to  give  them  in  capsule  form:  e  g.,  balsam, 
cubebs,  and  copaiba  5  to  10  minims  each,  as  these  are  said  to  be 
stimulating  and  at  the  same  time  soothing  to  the  urethral  mucosa. 
In  the  very  early  stage  it  is  even  better  to  administer  sandalwood 
oil  in  doses  of  about  ten  minims,  three  times  a  day.  Sandalwood 
oil  is  usually  well  borne  by  the  stomach,  but  is  more  or  less  irritating 
to  the  kidneys  as  a  result  of  its  over  stimulating  effect.  Therefore, 
it  often  causes  considerable  back-ache  and  nephralgia.  It  possesses 
the  properties,  however,  of  rendering  the  urine  bland  and  non- 
irritating.     The  copaiba  and  cubebs  on  the  other  hand  are  very  apt 


2S  URETHRITIS. 

to  cause  gastric  disturbance,  but  produce  very  little  discomfort  in 

the  kidneys.     Copaiba  may  in  its  untoward  effect  produce  a  general 

cutaneous  rash.   ^  These  balsamic  or  antiblennorrhagic  remedies,  as 

they  are  sometimes  called,  may  be  combined  with  the  sandalwood 

oil  giving  it  in  capsule  form,  as  follows: 

li      Balsam  copaiba itl  ij 

Ol.  cubebs tt\  ij 

Ol.  sandalwood itL  vj  M 

Fiat  capsula  No.  i. 
Sig.:  Two  capsules  three  times  a  day.* 

The  local  medication  in  acute  urethritis  is  probably  best  and 
most  efficient  in  the  form  of  hand  injections.  These  consist  in 
stimulating  antiseptic  solutions,  which  are  not  only  destructive  to 
gonococci  and  other  pyogenic  organisms  but  non-irritating  to  the 
mucous  membrane  of  the  urethra.  The  astringents,  used  for  the 
purpose  of  restoring  as  much  as  possible  the  normal  integrity  of  the 
urethra,  are  reserved  for  the  later  or  terminal  stage  of  the  disease. 
Just  when  to  begin  the  use  of  these  injections  has  been  the  subject 
of  much  mooted  discussion.  Some  cases  even  during  the  increasing 
stage  are  materially  benefited,  whereas,  in  others  it  may  be  pro- 
ductive of  harm.  If,  however,  the  injections  are  to  be  used  in  the 
early  stages,  the  ingredients  should  be  sufficiently  bactericidal, 
without  irritation  to  the  protective  epithelium.  Innumerable  com- 
binations have  been  suggested  but  only  those  that  have  been  found 
particularly  effective  in  the  hands  of  the  author  wall  be  given  con- 
sideration in  this  chapter.  (For  additional  formulee  see  end  of  this 
volume.) 

In  the  early  stages  where  an  antiseptic  injection  is  required  the 
following  is  very  useful: 

I^      Iodine  (crystals) 

Kalii  iodidi  aa grs.  xv 

Phenol gtts.  xij 

Argyrol grs.  Ixxv 

AquEe  dist.  q.  s.  ad f  S  iij  M 

Sig.:     Inject  syringeful  night  and  morning,  after  urinating,  and  retain  for 
three  minutes. 

*  See  list  of  formulae  at  end  of  volume. 


TREATMENT    OF   ACUTE   ANTERIOR    URETHRITIS. 


29 


iff 


pm, 


When  the  condition  becomes  subacute,  or  arrives  at  the  stage  of 
decline  and  no  complications  have  developed,  it  is 
then  that  more  astringent  injections  into  the  anterior 
urethra  are  particularly  indicated.  These  are  not 
only  convenient  but  most  beneficial  at  this  time. 
It  is  important  that  the  proper  kind  of  syringe  be 
selected.  It  may  be  made  of  rubber  or  glass  with 
rubber  tip,  in  which  event  the  nozzle  should  be  blunt 
and  the  capacity  of  the  syringe  not  over  four  drachms. 
(Fig.  3.)  The  patients  will  readily  acquire  the  skill 
of  using  these  injections  when  once  properly  in- 
structed. Among  the  most  effective  agents  may  be 
mentioned  nitrate  of  silver  1-10,000  and  gradually  in- 
creasing the  strength  up  to  i-iooo.  Various  modi- 
fications, e.g.,  protargol  i-iooo  to  i-ioo;  argyrol  5 
to  25  per  cent,  are  also  recommended  measures. 
Zinc  sulphate,  acetate,  sulphocarbolate,  i— 1000  to 
100,  zinc  or  potassium  permanganate  1-5000  to  2000, 
muriate  of  hydrastin  1-500  to  100  are  likewise  ex- 
cellent agents  in  many  cases  where  silver  salts  are  in- 
efficient. Silver  nitrate  has  the  virtue  of  promptly 
destroying  gonococci,  but  it  unfortunately  coagulates 
the  albumin  in  the  tissues,  and  besides  is  irritating. 
This  coagulum  prevents  its  action  upon  the  deeper 
tissues,  where  the  organism  really  abides.  The 
newer  salts,  e.g.,  argyrol,  protargol,  etc.,  possess  the 
antiseptic  properties  without  any  untoward  effect 
upon  the  tissues,  and  hence  the  penetrating  effect  is 
not  prohibited. 

Irrigations. — Another  method  of  local  treatment 
which  is  efficient  when  skillfully  used,  consists  in 
irrigation  of  the  urethra  by  means  of  hydrostatic 
pressure,  with  large  quantities  of  warm  solutions, 
e.g.,  of  potassium  permanganate,  etc.  The  entire 
canal  may  be  thus  cleansed.     A  sufficient  pressure  can  be  exerted 


Fig.    3  — 

Urethral  hand 

syringe. 


30 


URETHRITIS. 


to  overcome  the  action  of  the  compressor  urethra  muscles.  Valen- 
tine's irrigating  apparatus  (Fig.  4)  may  be  used  for  this  purpose  or 
this  can  be  improvised  by  using  a  fountain  syringe,  with  a  blunt 

end  rubber  or  preferably  glass  nozzle.  '  The 
patient's  wearing  apparel  should  be  protected 
with  a  towel  or  rubber  apron  and  the  patient 
seated  on  the  edge  of  a  chair  holding  a  basin 
to  catch  the  escaping  return  fluid.  When 
only  the  anterior  urethra  is  to  be  irrigated  the 
vessel  containing  the  solution  should  be  about 
two  feet  above  the  level  of  the  penis.  The 
irrigating  fluid  should  be  as  warm  as  the  pa- 
tient can  comfortably  tolerate.  The  tip  of 
the  nozzle  must  not  enter  the  urethra.  The 
gland  is  previously  washed  and  grasped  on 
either  side  by  the  thumb  and  index  finger  of 
one  hand  so  as  to  know  whether  or  not  the 
urethra  is  being  over  extended.  Janet's 
METHOD  of  treatment  is  as  follows:  Irrigate 
the  first  four  or  five  days  with  1—5000  potas- 
sium permanganate.  On  the  third  day  include 
the  posterior  urethra.  For  the  next  ten  days 
irrigate  the  entire  tract  daily,  gradually  in- 
creasing the  strength  of  the  solution  until  a 
proportion  of  i— 1000  or  even  1—500  is  reached 
on  about  the  tenth  day.  After  this  time  it  is 
gradually  diminished  in  strength. 

The    application    of    this    method   is   not 

always  practical,  because  it  is  both  difficult 

and  expensive  on  the  part  of  the  physician  as 

well  as  the  patient. 

Various  solutions  have  been  assigned  for  this  purpose.     These 

are:  nitrate  of  silver  i-iooo,  potassium  permanganate  1-5000,  zinc 

sulphate  1-5000,  protargol  1-500,  argyrol  i-ioo,  bichloride  of  mer- 

cur}^  1-10,000. 


Fig.  4. — Valentine 
irrigator. 


EXAMINATION    OF    THE    URINE   IN    URETHRITIS.  3T 

Prognosis. — In  an  ordinary  uncomplicated  case  of  urethritis, 
the  disease  will  run  a  definite  course  toward  recovery.  Before  a 
case  may  be  pronounced  cured  there  must  be  a  complete  cessation  of 
discharge  and  absence  of  all  subjective  and  objective  symptoms. 
The  urine  must  be  perfectly  clear.  If  a  microscopic  examination 
for  gonococci  is  negative,  the  treatment  should  be  discontinued. 
If  after  the  lapse  of  a  week  or  ten  days  without  treatment  and  still  no 
recurrence  of  symptoms  he  may  be  placed  on  what  is  called  the' 
provocative  test.  This  consists  simply  in  ordering  the  patient  to 
drink  several  glasses  of  beer  and  present  himself  the  following  day. 
Its  effect  is  carefully  noted.  If  there  is  then  absolutely  no  trace  or 
symptoms  of  the  infection  in  the  urine  the  patient  may  be  considered 
cured. 

Ricord's  maxim  ^^ Everybody  knows  when  gonorrhoea  begins,  hut 
God  only  knows  when  it  will  end/'  should  not  be  forgotten  in  promis- 
ing the  patient  a  cure  within  a  definite  period  of  time.  Should  the 
urethral  mucosa  be  damaged  during  the  infection,  the  urethra 
seldom  if  ever  regains  its  perfectly  normal  condition. 

EXAMINATION  OF  THE  URINE  IN  URETHRITIS. 

During  the  course  of  treatment  of  acute  anterior  urethritis, 
examination  of  the  urine  is  extremely  important,  as  it  is  the  guide 
to  progress  of  the  infection  and  to  the  results  of  treatment.  If  the 
urine  is  examined  in  the  prodromal  stage,  or  period  of  incubation, 
its  substance  will  be  found  quite  clear  and  transparent,  containing 
but  few  flakes  or  tiny  filaments.  Within  the  next  24  hours,  however, 
there  is  added  some  pus  and  mucus  which  clouds  the  urine.  This 
opacity  usually  persists  throughout  the  florid  and  increasing  stages. 
If  the  urine  when  in  this  state  is  allowed  to  stand  for  a  few  hours 
there  will  be  noted  at  the  bottom  of  the  vessel  a  thick  layer  of 
yellowish-white  deposit.  There  may  also  be  seen  an  admixture  of 
blood  in  cases  where  there  has  been  some  hemorrhage.  The  blood 
and  pus  will  form  a  lower  layer  and  on  top  of  this  will  be  a  cloud  of 
mucus.     In  the  stage  of  decline,  these  elements  are  gradually  dimin- 


32  URETHRITIS. 

ished  in  quantity,  and  the  urine  becomes  more  transparent,  in  which 
will  be  seen  floating  flakes  of  epithelial  cells  and  mucus.  Gonor- 
rhoeal  threads  or  ^'tripper-fdden^^  may  consist  of  either  pus  or  mucus, 
and  pus,  mucus,  and  epithelial  cells  combined,  or  sometimes  simply 
the  epithelial  cells  held  together  by  mucin. 

The  character  of  the  thread  is  very  significant,  as  for  instance, 
when  they  contain  pus,  mucus,  and  epithelium,  they  can  be  recog- 
nized macroscopically  by  their  sinking  immediately  to  the  bottom 
of  the  vessel.  This  is  usually  indicative  of  a  chronic  exudative 
condition.  The  mucoid  filaments  float  about  and  sink  very  slowly. 
They  vary  in  length  and  thickness,  and  always  contain  few  or  more 
of  the  pus  cells.  These  are  found  with  the  abatement  of  the  acute 
symptoms.  Sometimes  the  filaments  of  the  urethral  exudate  are 
found  in  lumps  agglutinated  by  the  mucus,  and  if  examined  micro- 
scopically are  found  to  contain  mucoid  epithelium  indicative  of 
some  ulcerative  process  in  the  anterior  urethra.  This  is  an  indica- 
tion for  the  use  of  the  endoscope  as  a  means  of  definitely  localizing 
the  affected  area. 

The  Two  Glass  Test. — This  has  come  into  vogue  at  the  sugges- 
tion of  Thompson  and  is  universally  regarded  as  a  most  useful 
procedure  as  a  criterion  to  the  progress  of  the  disease.  The  method 
simply  consists  in  voiding  the  urine  into  two  conical-shaped  glasses. 
If  the  infection  is  in  the  anterior  urethra  only,  the  first  glass  will  be 
opaque  and  the  second  clear.  On  the  other  hand  if  the  posterior 
urethra  is  involved  and  the  secretion  is  copious  both  glasses  will  be 
cloudy  and  opaque.  The  reasons  for  this  are  obvious.  The  uncon- 
taminated  urine  washes  the  anterior  urethra  as  it  is  being  passed 
and  therefore  contains  the  debris.  The  remaining  urine  therefore 
seen  in  the  second  glass  comes  through  the  clean  canal  and  conse- 
quently is  clear.  When  the  posterior  urethra  is  also  the  seat  of  the 
morbid  process,  some  of  the  infectious  secretion  is  almost  sure  to 
contaminate  the  urine  contained  in  the  bladder,  hence  the  second 
and  even  the  third  glass  will  show  cloudy  urine  which  has  a  tendency 
to  persist  owing  to  its  deep-seated  infection  and  therefore  very  apt 
to  become  chronic. 


COMPLICATIONS    OF   ANTERIOR    URETHRITIS.  33 

Relapses  or  exacerbations  of  symptoms  very  frequently  occur 
in  the  declining  stage  of  urethritis  and  are  in  a  high  percentage  of 
cases  due  to  some  indiscretion  mainly  in  the  form  of  alcoholic  or 
sexual  indulgences. 

This  exacerbation  or  autoinfection  is  usually  the  result  of  an 
apparently  cured  gonorrhoea.  The  gonococci  may  be  lodged  in 
the  follicles  of  the  urethra  or  in  the  seminal  vesicle  and  prostate, 
which  are  expressed  into  the  urethra  after  some  indiscretion.  This 
soon  causes  a  profuse  purulent  discharge  which  subsides  again 
within  a  few  days. 


COMPLICATIONS  OF  ANTERIOR  URETHRITIS. 

These  may  be  summarized  as  follows: 

Chordee.  Phimosis. 

Hemorrhage.  Paraphimosis. 

Folliculitis.  Balanitis  and  posthitis.  ■ 

Periurethral  phlegmon.  Vegetations. 

Retention  of  urine.  Cowperitis. 

Arthritis.  Cavernitis. 

Gonorrhoeal  conjunctivitis.  Lymphangitis. 

Bubo.  Penitis. 


Gonorrhoeal  Ophthalmia. — This  is  fortunately  seldom  met  with 
except  in  infants  whose  eyes  have  been  infected  in  the  mother's 
vagina  from  gonorrhoeal  pus  during  delivery.  When_seen  in  adults, 
carelessness  on  the  part  of  the  patient  from  soiling  his  fingers  with 
the  gonorrhoeal  pus  and  transferring  it  by  this  means,  to  his  or  her 
own  eye,  is  the  usual  cause.  Gonorrhoeal  ophthalmia  is  always  a 
most  virulent  condition  and  is  more  common  among  men  than 
in  women.  It  may  be  limited  to  one  eye  or  may  later  involve 
both. 

Symptoms. — ^First  manifestation  of  the  eye  being  involved  may 
appear  as  soon  as  24  hours  after  the  infection.  The  earliest  symp- 
toms noticed  will  be  congestion  of  the  conjunctiva  and  sclera, 
3 


34  URETHRITIS. 

itching  of  the  lids,  soon  followed  by  lacrymation,  photophobia, 
sticking  of  the  lids,  and  the  collection  of  inspissated  mucus  in  the 
eyelashes.  These  symptoms  all  become  intensified  and  the  dis- 
charge becomes  profuse  and  purulent.  (Edema  pervades  the 
entire  organ  and  the  patient  complains  particularly  of  great  burning 
and  pain  in  the  eyeball,  radiating  up  over  the  forehead  and  temple. 
Constitutional  disturbances;  those  of  depression,  irritability,  and 
nervousness  and  slight  febrile  excitement  accompany  these 
symptoms. 

Prognosis. — It  is  always  unfavorable.  When  both  the  eyes 
are  involved  it  is  still  more  grave.  Ulceration  of  the  cornea  always 
adds  to  the  gravity  of  the  condition. 

If  the  treatment  is  begun  early  and  vigorously  persisted  in  there 
may  be  some  hope  of  checking  its  ravages.  The  seriousness  of 
gonorrhoeal  ophthalmia  may  be  appreciated  from  the  fact  that  cases 
have  been  reported  from  which  the  entire  eye  has  been  destroyed  in 
less  than  24  hours.  Should  the  disease  be  controlled  and  ulceration 
of  the  cornea  occur,  the  vision  is  always  more  or  less  impaired  as  a 
result  of  the  opacity.  The  age  of  the  person  is  also  a  factor  in  the 
prognosis. 

Diagnosis  depends  largely  on  the  findings  of  the  microscope. 

Treatment. — This  must  be  vigorously  instituted  and  persisted 
in  day  and  night.  Trained  nurses  should  be  employed  for  this 
purpose.  Persons  with  experience  in  this  class  of  cases  should  be 
always  given  the  preference.  It  is  best  where  the  means  do  not 
permit  the  employment  of  nurses  to  send  the  patient  immediately  . 
to  a  hospital  where  there  are  facilities  for  treating  these  conditions. 
Thorough  asepsis  and  the  most  careful  prophylaxis  must  be  insisted 
upon.  If  only  one  eye  is  affected  the  other  should  be  protected  by  a 
shield.  The  attending  persons  should  be  instructed  as  to  their 
duties. 

The  patient  should  be  isolated.  The  constant  application  of 
cold  compresses  is  absolutely  necessary.  These  should  consist  of 
small  thin  pieces  of  gauze  or  linen,  which  have  been  thoroughly 
chilled  upon  a  piece  of  ice.     In  this  manner  the  compresses  should 


COMPLICATIONS    OF  ANTERIOR   URETHRITIS. 


35 


be  changed  every  few  minutes  and  burned  after  once  used.  When 
the  condition  has  progressed  to  the  inflammatory  stage  the  con- 
junctiva sac  should  be  flushed  copiously  with  bone  acid  solution  as 
often  as  the  pus  accumulates,  after  one  of  these  irrigations  a  few 
drops  of  2  per  cent,  solution  of  silver  nitrate  should  de  dropped  into 
the  eye  once  daily.  Argyrol  25  per  cent,  may  also  be  used  for  this 
purpose.     This  should  be  persisted  until  signs  of  improvement  are 


Fig.  5. — Abscess  of  the  preputial  follicle. 


noted,  then  gradually  less  frequent  and  then  finally  some  mild 
astringent,  e.  g.,  zinc  sulphate  solution. 

This  local  treatment  may  be  subordinated  with  constitutional 
tonics,  light  diet,  and  the  bowels  kept  regular.  ■ 

Periurethral  infection  occurs  not  infrequently  where  there  is  a 
rupture  of  an  infected  follicle,  and  sometimes  this  happens  behind 
the  seat  of  a  stricture. 

Infiimmation  of  the  preputial  follicles  sometimes  originates 
in  the  course  of  acute  gonorrhoea  and  is  seen  between  the  two 
layers  of  the  prepuce  in  the  form  of  a  small  nodule,  about  the  size  of 


36  URETHRITIS. 

a  pea,  which,  occurs  singly  but  may  sometimes  be  present  in  pairs. 
(See  Fig.  5.) 

Retention  of  Urine. — As  a  complication  of  anterior  urethritis 
depending  somewhat  on  the  extent  of  the  inflammatory  swelling 
of  the  mucous  membrane,  there  may  be  a  diminution  of  the 
caliber  of  the  canal  with  deep  muscular  spasm,  causing  retention 
of  urine. 

A  temporary  congested  condition  often  directly  due  to  sexual  or 
alcoholic  excesses,  may  give  rise  to  similar  symptoms.  (See  chapter 
Retention  in  Stricture,  etc.) 

Cowperitis. — Involvement  of  Cowper's  glands  is  usually  uni- 
lateral but  may  involve  both  glands.  These  lie  on  either  side  of 
the  urethra  in  the  corpus  spongiosum  between  the  layers  of  the 
triangular  ligament  with  their  ducts  emptying  into  the  bulbous 
portion  of  the  anterior  urethra.  The  early  symptoms  are  inflam- 
matory, but  the  condition  in  a  large  percentage  of  cases  soon  under- 
goes suppuration.  The  symptoms  are:  pain,  usually  pulsating, 
swelling,  and  a  feeling  of  heaviness  in  the  perineum,  which  later 
becomes  more  swollen,  discolored,  and  oedematous.  The  oedema 
may  extend  up  into  the  scrotum.  Cowperitis  is  very  frequently 
attended  with  more  or  less  constitutional  disturbance.  (See  p.  77, 
Abscess  of  Cowper's  glands.) 

Gonorrhoeal  arthritis  or  gonorrhoeal  rheumatism,  is  an 
inflammation  principally  of  the  joints,  fascim,  bursce,  and 
tendinous  sheaths,  occurring  as  a  complication  of  urethri- 
tis. It  is  much  more  frequently  seen  in  men  than  in  women. 
This  inflammatory  condition  of  the  joint  is  primarily  caused  by  the 
gonococcus  and  its  toxins.  It  has  no  definite  period  of  outset.  The 
BURS^  which  are  usually  attacked  are  those  in  front  of  the  tendon 
Achilles  and  the  one  beneath  the  os  calcis.  The  tendinous 
SHEATHS  may  also  become  involved  alone  or  secondarily  to  joint 
lesions.  These  sheaths  are  usually  the  extensors  of  the  fingers,  and 
the  dorsal  flexors  of  the  toes.  The  synovial  membrane  may  also 
be  the  seat  of  gonorrhoeal  infections.  This  form  of  arthritis  is 
usually  monarticular. 


COMPLICATIONS    OF   ANTERIOR    URETHRITIS.  37 

The  symptoms  in  the  prodromal  period  which  may  be  more  or 
less  severe,  are:  pain  in  the  affected  joint,  slight  chill,  general 
myalgia,  malaise,  and  mild  fever.  The  effusion  into  the  part  is 
either  serous,  sero-fibrinous,  sero -purulent,  or  purulent  in  character. 
The  knee-joint  is  the  one  most  frequently  attacked.  The  joint  is 
much  enlarged  and  tender,  and  the  overlying  skin  red  and  tense. 
Pain  may  be  dull  and  continuous  or  pulsating  and  sharp,  and  is 
usually  attended  with  nocturnal  exacerbations.  The  mobility  of 
the  part  is  impaired.  This  process  continues  ordinarily  in  most 
favorable  cases  from  five  to  eight  weeks  but  may  persist  for  months. 
When  the  effusion  is  purulent,  its  duration  is  indefinite.  Sometimes 
gonorrhoeal  arthritis  may  be  insidious  in  its  onset  and  develop  into 
a  chronic  condition.  The  affection  then  is  attended  with  relatively 
little  pain.  The  joint  is  swollen  and  may  result  in  permanent 
deformity.  Where  the  involvement  is  polyarticular,  the  course  is 
frequently  less  severe.     It  generally  attacks  the  large  joints. 

The  important  lesion  of  gonorrhoeal  rheumatism  is  synovitis 
which  is  either  serous,  sero-fibrinous,  or  sero-purulent. 

The  COURSE  of  gonorrhoeal  arthritis  depends  largely  on  the  nature 
of  the  effusion.  The  best  prognosis  may  be  given  and  the  quickest 
results  obtained  where  the  lesion  is  simply  a  serous  exudate.  In 
chronic  affections  of  the  joints,  ankylosis  may  result,  and  the  process 
may  go  so  far  as  to  attack  the  muscles,  tendinous  sheaths,  and 
bursae. 

Complications. — These  are  most  commonly,  arthritis ^  bursitis, 
and  inflammation  of  the  tendinous  sheaths. 

Diagnosis. — A  history  of  gonorrhoea  either  just  prior  or  a  co- 
existing urethritis,  will  in  the  majority  of  cases  establish  the  nature 
of  the  affection.  The  absence  of  sweating  and  the  tendency  to 
attack  the  larger  joints  are  also  characteristic  of  specific  arthritis. 
Examination  of  the  urine  should  materially  aid  the  diagnosis.  The 
following  table  is  convenient  in  making  a 


38 


URETHRITIS. 


DIFFERENTIAL  DIAGNOSIS  OF 


Gonorrhaeal  Rheumatism. 

(By  Fournierj  and 

Usually  monarticular,  less  commonly 
polyarticular.  In  the  latter  instance 
the  joints  are  affected  consecutively. 

Fever  and  constitutional  disturb- 
ances, mild.  Symptoms  when  acute 
are  mild  in  their  duration. 

Caused  by  gonorrhoeal  infection. 

Rare  in  women. 

Secondary  hydrarthrosis  common. 

No  sweating. 

Urine  not  modified. 

Cardiac  complications  rare. 

Synovitis  of  tendons,  sheaths,  bursae, 
etc. 

Tendency  to  recurrence  with  suc- 
ceeding gonorrhoeal  infections. 

Salicylates  inefficient. 


Simple  Rheumatism. 

modified  by  the  author.) 

Most  frequently  polyarticular  in- 
volving several  joints  simultane- 
ously. 

Systemic  phenomena,  severe  and 
persistent. 

Caused  by  rheumatic  diathesis  and 

cold  chiefly. 
Common  in  male  and  female. 
Secondary  hydrarthrosis  rare. 
Abundant  sweat,  acid  in  character. 
Urine  specially  modified. 
Cardiac  complications  frequent. 
Sheaths  and  bursae  not  involved  in 

the  flammatory  process. 
Recurrences  are  not  dependent  on 

exacerbation  of  urethritis. 
Salicylates  beneficial. 


Prognosis. — Depends  on  the  extent  of  the  involvement  and  the 
vitality  of  the  patient.  Usually  from  one  to  three  months  is  the 
duration. 

Treatment. — It  is  of  the  greatest  importance  first  to  remove 
the  infecting  source  of  the  joint  lesion,  the  seat  of  which  is  in  the 
urethra,  hence,  measures  must  be  immediately  taken  to  eradicate 
the  infective  foci.  This  consists  in  instillations  into  the  deep  urethra 
of  about  two  drachms  of  1/2  to  i  per  cent,  nitrate  of  silver  solution, 
by  means  of  a  catheter  or  Keyes-Ultzman  syringe. 

The  local  treatment  of  the  joint  requires  rest  in  bed  and  such 
measures  as  applications  of  lead  water  and  laudanum,  if  there  be 
much  redness  and  swelling.  Internally  opiates  may  be  given  for 
the  relief  of  the  pain. 

When  the  acute  symptoms  subside  Taylor  recommends  blistering 


DIFFERENTIAL    DIAGNOSIS    OF    RHEUMATISM.  39 

with  cantharidal  collodion  or  a  fly  blister,  the  blister  kept  open 
with  tartar  emetic  ointment. 

Aspiration  and  irrigations  of  the  affected  joint,  where  there  is 
extensive  hydrarthrosis  and  in  suppurative  cases  is  also  advised. 
In  mild  cases,  mercurial  ointment  combined  with  ichthyol  or  Ung. 
Belladonnae  or  compresses,  wet  supersaturated  solutions  of  mag- 
nesium sulphate  may  be  used  often  with  considerable  benefit. 

Should  the  condition  become  chronic,  dry  heat,  massage,  etc., 
can  be  used,  and  is  frequently  attended  with  good  results. 

When  properly  applied  and  controlled.  Bier's  treatment  of  joints 
acutely  involved  by  gonorrheal  infection  produces  definite  bene- 
ficial results.  Relief  of  symptoms  is  striking,  the  disease  is  cut 
short,  and  permanent  damage  to  the  joint  is  prevented.  The 
hyperemia  produced  must  be  intense.  Of  course,  the  pulse  must  be 
obliterated.  Usually  the  fault  lies  in  not  sufficiently  obstructing 
the  return  circulation.  If  the  oedema  at  any  time  becomes  too  pro- 
nounced, or  signs  of  blocked  circulation  appear,  remove  the  bandage, 
elevated  the  limb  for  one  hour,  then  replace  the  bandage.  In- 
struct the  patient  to  test  frequently  the  temperature  of  his  hand  or 
foot,  as  the  case  may  be,  and  keep  him  under  observation. 

Bubo. — Gonorrhceal  bubo  is  sometimes  seen  where  the  lym- 
phatic glands  of  the  groins  become  enlarged.  They  are  in  most 
instances  seen  to  be  inflammatory,  and  but  rarely  undergo  suppura- 
tion unless  where  there  is  a  tuberculous  diathesis  or  cachexia. 

Treatment. — The  principles  of  the  local  treatment  are  practically 
the  same  as  for  chancroidal  bubo  (q.v.). 

Bacterin  and  Serum  Therapy. — Sir  A.  E.  Wright  demonstrated 
that  the  subcutaneous  injection  of  killed  pathogenic  bacteria  pro- 
duces in  the  blood  and  tissue  fluids  of  the  individual  a  substance 
(to  which  he  has  given  the  name  ''opsonin")  which  combines  with 
the  corresponding  infecting  organisms  and  so  modifies  them  that 
the  phagocytes  readily  take  them  up  (phagocytosis).  The  prep- 
arations of  killed  bacteria  used  for  this  purpose  Wright  termed 
"bacterial  vaccines"  or  bacterins.  Being  suspensions,  there  is  a 
tendency  for  the  bacteria  to  settle  on  standing;  hence  the  vial  should 


40  URETHRITIS. 

be  shaken  before  the  syringe  is  filled  and  the  latter  should  be  shaken 
before  injecting. 

Actions  and  Uses. — The  use  of  many  of  these  vaccines  is  in  the 
experimental  stage.  Bacterial  vaccines  are  often  prepared  from 
cultures  obtained  from  the  individual  to  be  treated  (autogenous 
vaccines) ;  these  usually  give  the  best  results.  In  fact  some  authors 
maintain  that  "stock"  vaccines  should  be  used  only  when  it  is  im- 
practicable to  secure  the  autogenous  agent. 

Bacterins  are  used  to  aid  the  production  of  an  active  immunity. 
Great  care  and  skill  are  necessary  for  their  proper  use  and  no 
definite  statements  as  to  dosage,  etc.,  can  be  given.  The  physician 
must  be  guided  by  the  condition  of  the  patient  and  the  manner  in 
which  the  latter  reacts  to  the  treatment. 

GoNOCOCCus  Vaccine. — Gonococcus  vaccine  has  been  used  with 
much  success  in  subacute  and  chronic  gonococcus  infections  involv- 
ing the  prostate,  joints,  eyes,  etc. 

Gonococcus  Bacterin. — Marketed  in  ic.c.  vials;  each  c.c.  con- 
taining about  50,000,000  cocci  suspended  in  physiological  salt  solu- 
tion, with  phenol  or  trikresol  added  as  a  preservative. 

The  treatment  of  acute  and  subacute  localized  gonorrhoeal  in- 
fections by  bacterins  has  been  attended  with  some  success,  but  on 
the  whole  has  been  disappointing  in  so  far  as  permanent  results 
being  attained. 

The  question  of  personal  or  autogenous  vaccines,  as  preferred 
to  the  stock  vaccines,  has  received  considerable  attention,  the 
consensus  being  in  favor  of  the  autogenous  variety.  The  doses  vary 
anywhere  from  20  to  500,000,000  organisms  administered  hypoder- 
matically  at  intervals  from  3  to  7  days.  The  site  of  injection  should 
be  thoroughly  cleansed  and  rendered  aseptic  with  the  hypodermic 
needle  sterilized.  Manufacturers  are  now  putting  bacterins  up  in 
syringes  ready  for  use.  The  point  of  application  should  be  near  the 
focus  of  infection  being  given  into  the  cellular  tissues. 

Mixed  Bacterins. — Preferably  autogenous,  have  been  given  with 
considerable  success,  and  will  no  doubt  be  more  generally  employed 
in   the  future.     Bacterin   treatment   must   supplement   with  local 


DIFFERENTIAL   DIAGNOSIS    OF    RHEUMATISM.  4 1 

hygienic  constitutional  measures.  They  are  not  without  some  merit 
in  suitable  cases,  especially  where  there  is  metastatic  involve- 
ment, but  their  limitations  must  be  borne  in  mind. 

GoNOCOCCUs  SERUM  is  uot  so  generally  employed  perhaps  as  the 
bacterins,  but  will  often  be  found  of  much  benefit  when  the  bacterins 
fail.  The  serum  is  put  up  in  2  c.c.  ampules,  and  may  be  given  in 
doses  as  large  as  6  to  8  c.c.  single  injection.  The  technic  of  its 
administration  is  the  same  as  for  bacterins.  The  local  reaction 
may  be  more  severe  and  urticaria  sometimes  follows  its  use. 

Gonococcal  metastatic  lesions  of  the  subacute  and  chronic  type 
are  often  greatly  improved  and  cure  hastened  by  the  inoculation 
treatment.  The  best  results  are  seen  in  arthritis  and  in  lesions  of 
the  periosteum  and  tendon  sheaths.  In  acute  arthritis  the  results  are 
not  so  favorable,  and  in  cases  with  high  fever  and  severe  toxic 
symptoms  the  employment  of  vaccines  should  be  postponed.  In 
urethritis  gonococcus  vaccines  have  given  indifferent  results. 

Balanitis  is  an  inflammation  of  the  mucous  membrane  of  theglans 
penis  while  in  posthitis  the  inflammatory  process  is  confined  to 
the  mucous  membrane  of  the  prepuce.  When  both  glands  and 
prepuce  are  involved  it  is  termed  Balano-posthitis.  These  con- 
ditions are  simply  due  to  the  action  of  irritating  secretions  which  are 
retained,  being  superinduced  by  a  tight  or  exuberant  prepuce.  The 
surfaces  of  these  mucous  membranes  will  be  found  red,  painful, 
slightly  ulcerated,  and  purulent,  sometimes  resembling  chancroid.* 

Vegetations. — Warty  excrescences  which  appear  upon  the 
mucous  membrane  of  the  glans  and  prepuce  are  also  the  result 
of  irritation.  They  consist  of  piled  up  proliferating  epithelium 
forming  the  covering  of  highly  vascular  growths.  These  often 
attain  an  enormous  size  and  extend  over  considerable  area.* 

Lymphangitis. — This  complication  involves  the  lymphatic 
vessels  of  the  penis.  It  is  attended  with  swelling  and  oedema  of 
the  part.  It  is  usually  red,  and  is  attended  with  relatively  little 
pain.* 

*  See  Chapter  on  Affections  of  the  Penis. 


42  URETHRITIS. 

ACUTE  POSTERIOR  URETHRITIS. 

Infection  of  the  deep  urethra  not  regarded  as  a  compHcation  of 
anterior  urethritis  but  rather  as  a  sequence  of  the  gonococcic  invasion 
of  the  anterior  urethra.  Some  authorities  claim  that  in  80  to  90 
per  cent,  of  the  cases  of  anterior  urethritis  there  is  more  or  less 
posterior  involvement.  This  is  simply  due  to  the  extension  of  the 
inflammatory  process  by  continuity  from  the  penile  to  the  deep 
urethra.  Posterior  urethritis  may  occur  independently  of  anterior 
urethritis  from  such  causes  as  injury  by  instrumentation,  calculi, 
hyperacidity  of  urine,  and  from  instillation  into  the  deep  urethra. 

Symptoms. — There  is  no  definite  chronology  of  symptoms.  The 
sense  of  burning  in  the  deep  urethra  and  perineum,  especially  after 
micturition,  and  a  feeling  of  heaviness  in  the  testes  are  characteristic. 
There  is  usually  a  sudden  cessation  of  discharge  from  the  meatus 
and  an  increased  desire  to  urinate.  The  two  glass  test  will  show  an 
opacity  of  the  urine  and  the  possibility  of  confounding  this  cloudi- 
ness with  that  of  phosphaturia  must  be  kept  in  mind  and  hence 
excluded  by  the  acetic  acid  test.*  The  burning  pain  felt  in  the  deep 
urethra  is  aggravated  at  the  end  of  urination,  giving  rise  to  a  sense 
of  heaviness  in  the  perineum,  often  associated  with  spasm,  which 
may  occasion  a  slight  terminal  hematuria.  The  increased  frequency 
of  urination  may  be  both  diurnal  and  nocturnal,  but  is  usually  more 
pronounced  during  the  day,  when  the  patient  is  up  and  about. 
Pain  in  the  glans  penis  felt  at  the  end  of  urination  may  also  be 
present.  Following  in  this  train  of  symptoms  may  be  partial  or 
complete  retention  and  relative  incontinence  of  urine.  Retention 
in  initial  infections  is  often  spasmodic,  but  in  cases  with  a  previous 
venereal  history  it  may  be  due  to  stricture,  prostatitis,  hypertrophy 
or  abscess  of  the  prostate.  Digital  rectal  examination  of  the  pros- 
tate will  find  this  organ  more  or  less  tender,  painful  to  pressure,  but 
not  enlarged.  Albuminuria  is  another  symptom  which  frequently 
accompanies  a  severe  posterior  infection.  Irritability  of  the  sexual 
centers  as  a  symptom  of  posterior  urethritis  is  often  present,  giving 

*  See  Chapter  on  Examination  of  the  Urine. 


ACUTE   POSTERIOR   URETHRITIS.  43 

rise  to  chordee,  priapism,  etc.  The  acute  symptoms  usually  last  but 
a  few  days. 

Diagnosis. — There  being  no  discharge  visible  at  the  meatus, 
the  patient  experiences  very  little  or  no  discomfort,  therefore  in  the 
average  case  the  patient  is  ignorant  of  any  deep  involvement.  It 
is  not  until  an  exacerbation  from  some  cause  occurs  that  he  realizes 
the  true  state  of  affairs.  If  the  urine  is  examined  by  the  two  glass 
test,  both  urines  will  be  opaque  and  will  be  found  to  contain  an 
abundance  of  various  sized  threads,  more  especially  in  the  second  glass. 
The  latter  urine  may  contain  the  prostatic  filaments,  as  the  result  of 
muscular  contraction.  Where  there  is  an  exacerbation  of  a  chronic 
posterior  urethritis,  the  symptoms  are  more  pronounced.  The 
patient  complains  particularly  of  an  increased  frequency  of  urina- 
tion, which  may  be  accompanied  with  more  or  less  pain  and  dis- 
comfort at  its  termination.  This  pain  may  be  sharp  or  dull  and 
heavy,  radiating  into  the  rectum,  scrotum,  and  groins.  In  other 
cases  where  the  condition  assumes  a  chronic  form  the  symptoms  do 
not  become  manifest  perhaps  until  there  has  been  some  alcoholic 
or  sexual  indulgences.  The  patient's  general  mental  and  physical 
vigor  in  most  cases  sooner  or  later  becomes  impaired,  and  in  many 
instances  they  become  sexual  hypochondriacs. 

Pathology. — Gonorrhoeal  infections  in  the  posterior  urethra 
generally  produce  a  catarrhal  and  exudative  condition,  involving 
the  superficial  and  submucoid  structures,  which  may  result  in 
thickening  or  in  granular  and  congested  areas  or  erosions,  as  a  conse- 
quence of  epithelial  proliferation  and  desquamation.  The  patches 
may  be  distinctly  seen  by  the  endoscope. 

The  COMPLICATIONS  of  Posterior  Urethritis  are: 

Orchitis.  Seminal  Vesiculitis. 

Epididymitis.  Ascending  Infection. 

Urethrocystitis.  Peritonitis. 

Prostatitis.  Endocarditis. 

Deferentitis.  Rheumatism. 

Spinal  Meningitis  (extremely  rare)  and  Inflammation  of  the  Verumontanum. 

Duration  is  always  uncertain  and  the  condition  may  last  many 


44  URETHRITIS. 

weeks  or  months,  depending  largely  upon  the  treatment  and  the 
co-operation  of  the  patient.  The  declining  stage  is  marked  by  the 
general  amelioration  of  symptoms  and  the  gradual  improvement  is 
shown  in  the  two  glass  test. 

Prognosis. — In  the  average  case  a  cure  may  be  effected  in  from 
one  to  two  months.  It  is  impossible  to  foretell  complications,  but 
the  progress  to  recovery  is  usually  favorable. 

Treatment. — Rest  as  much  as  possible  should  be  advised.  The 
urine  must  be  kept  bland  and  non-irritating  by  the  ingestion  of 
plenty  of  water,  milk,  or  butter-milk.  All  hand  injections  must  be 
immediately  discontinued.  Urotropin  in  doses  from  5  to  8  grains 
renders  the  urine  antiseptic;  prevents  decomposition,  and  also  irri- 
tation by  keeping  it  neutral.  If  there  be  much  tenesmus  or  pain 
an  opium  (1/2  gr.)  suppository  in  the  rectum  will  give  relief.     Sodium 


Fig.   6. — Keyes-Ultzman  syringe. 

bromide,  sandal  wood  oil,  etc.,  may  also  be  given  pro  re  nata. 
Local  treatment  is  likewise  essential.  After  the  acute  symp- 
toms have  abated,  instillations  by  means  of  a  Keyes-Ultzmann 
syringe  (Fig.  6)  or  soft  rubber  catheter,  into  the  posterior  urethra 
and  bladder  should  be  given.  Silver  nitrate  solution  21/2  grs.  to 
the  ounci\  argyrol  10  to  20  per  cent,  and  protargol,  1/2  to  2  per  cent, 
may  be  employed  for  this  purpose. 

Gonorrhoeal  cystitis  is  fortunately  a  very  rare  occurrence, 
as  the  condition  is  more  often  confined  to  the  trigone  of 
the  bladder,  which  is  termed  urethro-cystitis.  This  condition 
may  be  observed  by  means  of  the  cystoscope.  (See  chap,  on 
Cystoscopy.)  When  this  portion  of  the  bladder  is  involved,  the 
principal  symptoms  are  pain  over  the  symphysis  pubis,  malaise, 
and  fever.     The  urine  is  turbid  in  both  glasses  and  contains  spindle 


CHRONIC    URETHRITIS.  45 

shaped  epithelium,  pus,  and  bacteria.  In  the  early  stages  it  is  acid, 
but  later  becomes  alkaline  and  ammoniacal.  This  condition  may 
run  its  course  in  from  i  to  2  months  or  may  become  subacute  or 
chronic.  Sometimes  the  pain  is  greatly  aggravated  at  the  end  of 
urination.  Micturition  may  be  frequent  both  night  and  day.  Usu- 
ally this  affection  remains  superficial;  in  other  cases  it  involves  the 
submucoid  tissues,  which  form  is  called  ^^ parenchymatous^^  cystitis. 
This  may  go  on,  resulting  in  ulceration  and  is  often  the  forerunner 
of  ascending  infection. 

Diagnosis. — The  diagnosis  is  based  upon  the  history  of  the  orig- 
inal infection  and  the  examination  of  the  urine.  The  urine  test 
should  be  made  conclusive  by  testing  for  urates,  phosphates,  and  by 
the  microscope.  These  elements  may  be  readily  tested  (see  chap, 
on  Exam,  of  urine). 

Treatment. — Effort  should  be  directed  toward  keeping  the  urine 
bland  and  unirritating.  Highly  seasoned  foods,  condiments,  and 
alcoholics,  are  to  be  interdicted.  The  patient  should  rest  as  much 
as  possible.  Urotropin  or  dilute  nitro-muriatic  acid  are  useful  in 
neutralizing  the  alkalinity.  Soda  salicylate,  or  sodium  benzoate  may 
also  be  given  for  their  aseptic  effects  upon  urine.  Eucalyptus; 
boric;  salol;  celestin  vichy,  are  also  additional  measures  often  pro- 
ductive of  much  good.* 

The  bowels  should  be  kept  active  by  laxatives  if  necessary. 

The  local  treatment  consists  of  warm  irrigations  of  saturated  boric 
acid;  normal  salt;  nitrate  of  silver  (1:8000);  and  potassium  per- 
manganate (i  :  5000)  solutions. 

CHRONIC  URETHRITIS. 

Synonyms. — Gleet,  chronic  gonorrhoea.' 

Etiology.— There  are  innumerable  causes  which  may  directly  or 
indirectly  occasion  chronicity  of  urethral  infections  of  gonorrhoeal 
origin.  Chronic  urethritis  is  often  attributed  to  improper  treatment, 
but  frequently  the  patients  thems'elves  are  to  blame,  more  especially 

*  See  list  of  formulas  at  end  of  volume. 


46  URETHRITIS. 

in  cases  where  a  history  of  improper  sexual  hygiene  or  alcohoHc 
indiscretions  is  given.  Very  often  gouty,  strumous,  or  cachectic 
diatheses  of  the  individual  enter  into  the  etiology  and  therefore 
must  be  taken  into  consideration,  either  as  a  direct  or  predisposing 
element.     Syphilis,  too,  will  sometimes  induce  chronic  urethritis. 

Among  the  local  causes  which  are  chiefly  responsible  for  the 
persistence  of  the  symptoms  are  congested  or  granular  patches  and 
stricture,  but  among  the  many  other  conditions  which  may  be  enu- 
merated Sire:  folliculitis,  cowperitis,  edematous  folds,  superficial  ero- 
sions, necrotic  patches,  seminal  vesiculitis,  papillomatous  growths  in 
the  urethra,  juxta^rethral  sinus,  infection  of  the  sinus  pocularis,  hy- 
pertrophy of  the  prostate,  prostatitis,  peri-urethral  abscess,  mucous 
patches  in  the  urethra  and  genito-urinary  tuberculosis. 

The  sjmiptoms  of  chronic  anterior  urethritis  are  principally:  the 
so-called  morning  drop,  and  glueing  together  of  the  meatus.  Ex- 
amination of  the  urine  by  the  two  glass  test  will  show  either  one 
or  both  glasses  to  contain  threads. 

When  the  bulbous  or  deep  urethra  is  the  seat  of  a  chronic  ure- 
thral infection  there  may  or  may  not  be  any  discharge  visible  from 
the  urethra,  but  the  patient  will  usually  give  a  history  of  a  dis- 
charge occurring  some  time  or  other  during  the  day  with  no  further 
symptoms.  A  very  common  condition  encountered  under  such  cir- 
cumstances is  an  involvement  of  the  glands  of  littre  and  crypts 
of  Morgagni  which  is  sometimes  termed  folliculitis  or  still  better 
chronic  follicular  urethritis.  A  thorough  exploration  of  the 
parts  is  imperative  in  order  to  arrive  at  an  intelligent  understanding 
of  the  true  source  of  a  chronic  urethral  discharge.  The  condition 
of  the  mucous  membrane  of  the  urethra  should  also  be  determined 
by  means  of  the  endoscope. 

The  symptoms  of  chronic  urethritis  are  not  definite,  as  each  case 
is  practically  a  law  unto  itself,  and  depends  largely  upon  its  cause 
and  the  extent  of  the  infectious  processes. 

Diagnosis. — When  the  symptoms  persist  for  a  period  beyond 
the  subacute  stage,  which  may  be  said  to  last  four  months,  the  con- 
dition assumes  the  so-called  chronic  form.     A  patient  presenting 


CHRONIC    URETHRITIS.  47 

himself  with  an  infection  of  long  duration  must  be  thoroughly 
questioned  as  to  the  history  of  his  ailment  and  then  carefully  ex- 
amined. His  habits  should  be  ascertained  and  any  previous  vene- 
real history  noted.  He  should  be  instructed  to  pass  his  urine  into 
two  conical  glasses;  if  the  first  urine  is  turbid  and  the  second  clear, 
it  can  be  deduced  that  the  infection  is  limited  to  the  anterior  ure- 
thra, and  vice  versa,  if  the  second  glass  is  turbid  then  the  posterior 
urethra  is  the  seat  of  the  infection.  The  next  step  should  be  a 
rectal  examination  of  the  prostate  gland  and  the  seminal  vesicles 
to  ascertain  their  condition.  If  the  urethral  symptoms  are  not 
acute,  an  examination  of  the  urethra  with  the  bougie  (about  26 
French)  should  be  made,  noting  the  resistance  of  its  passage.  Ex- 
amine the  urethra  along  its  entire  length  to  determine  any  thick- 
ening or  follicular  involvement,  also  the  condition  of  the  Cowper's 
glands.  Supplementing  these  measures  the  endoscope  is  invalu- 
able in  localizing  definitely  any  morbid  areas  and  the  treatment  is 
directed  accordingly.  (See  chapter  on  Endoscopy.)  It  must  be 
remembered  that  strictures  are  a  prolific  cause  of  chronic  urethritis 
in  50  per  cent,  of  the  cases. 


^c== 


Fig.  7. — Guyon  syringe. 

Treatment. — When  the  infection  is  confined  to  the  anterior 
urethra,  the  tract  should  be  irrigated  with  warm  potassium  per- 
manganate solution  1-3000,  or  nitrate  of  silver  solutions  1-15,000 
to  1-10,000  every  two  or  three  days.  If  the  condition  is  a  follicular 
urethritis,  this  should  be  followed  by  the  passing  of  a  bougie 
lubricated  with  Finger's  or  Unna's  ointment  (see  formulas  at  the 
end  of  volume)  into  the  urethra  and  the  follicles  vigorously  mas- 
saged by  pressure  with  the  fingers  from  without  to  get  rid  of  the 
inflammatory  exudate  and  promote  resolution.  Should  the  entire 
length  of  the  urethra  be  infected,  the  procedure  must  be  supple- 
mented by  instillation  with  a  Keyes-Ultzman's  or  Guyon  syringe 


48 


URETHRITIS. 


W 


(Fig.  7)  or  soft  rubber  catheter,  of  nitrate  of  silver  (i  to  2  1/2  grs.  to 
the  oz.)  or  its  various  modifications  in  different  strengths  injecting 
from  2  to  4  drachms  at  each  treatment. 
Instillations  into  the  deep  urethra  every  third 
day  will  usually  suffice,  but  in  severe  cases 
may  be  resorted  to  daily  until  improvement 
follows. 

When  argyrol  is  used  for  this  purpose  it 
should  be  in  solution  from  5  to  20  per  cent.; 
protargol  1/2  to  2  per  cent.  Copper  sulphate 
1/2  to  I  per  cent,  may  also  be  employed. 
Should  any  circumscribed  morbid  areas  or  in- 
filtrations be  definitely  localized  by  the  urethro- 
scope, they  may  be  touched  directly  with  any 
of  these  agents  by  means  of  this  instrument. 
The  best  method  of  promoting  absorption  of 
infiltrated  tissues  is  by  pressure,  through  the  use 
of  sounds — preferably  Beneque's  double  curved 
bougie  or  Kollman  dilator  (Fig.  8) — supple- 
mented by  massage  from  without  over  the 
curve  of  the  instrument.  Should  the  flakes  or 
the  threads  in  the  urine  upon  microscopic 
examination  be  found  to  contain  no  bacteria, 
but  simply  consisting  of  desquamated  epithe- 
lium and  mucin  from  the  anterior  and  bulbous 
portion  of  the  urethra,  Finger's  ointment  will 
be  found  very  efficient  if  applied  to  the  mu- 
cous membrane  over  its  entire  surface  by  means 
of  a  long  wire  applicator  tipped  with  a  cotton 
swab.  When  posterior  urethritis  is  associated 
with  chronic  prostatitis  and  seminal  vesiculitis, 
the  subjective  symptoms  are  often  temporarily 
those  of  atonic  impotence.  In  such  instances 
deep  instillation  of  silver  solutions  and  massage  of  the  prostate  and 
vesicles,  via  the  rectum  every  third  day  and  the  passage  of  a  cold 


Fig.   8. — Kollman 
dilator. 


COMPLICATIONS    OF   POSTERIOR   URETHRITIS.  49 

steel   bougie  mil  usually  be  followed   by  improvement   within   a 
comparatively  short  time. 

The  Endoscope. — Its  diagnostic  and  therapeutic  uses  make  this 
an  invaluable  instrument  in  the  treatment  of  chronic  urethritis. 
The  morbid  changes  may  be  view^ed  without  discomfort  or  harm  to 
the  patient,  and  the  infected  follicles  be  distinctly  seen  in  deep  red, 
pus-exuding  spots.  The  color  of  the  mucous  membrane,  often 
congested  and  purplish;  granular  patches  and  the  thickened  appear- 
ance of  the  mucous  membrane;  hyperemia;  and  sometimes  papillo- 
mata,  erosions,  and  ulcerations,  may  be  observed.  Besides  localiz- 
ing the  inflammatory  focus  the  endoscope  permits  the  application 
of  remedies  to  these  lesions.  Probably  the  best  endoscopes  whiclj 
we  have  at  the  present  day  are  the  Otis  and  Swinburne  instruments. 

COMPLICATIONS  OF  POSTERIOR  URETHRITIS. 

Epididjmiitis. — As  a  complication  of  posterior  urethritis  the 
epididymis  very  frequently  becomes  the  seat  of  an  acute  inflamma- 
tion. The  diseased  process  may  be  confined  to  the  epididymis 
or  may  involve  by  ascending  infection  the  testicle  and  vas  deferens. 
An  acute  epididymitis  is  always  attended  vdth  an  effusion  of  lymph 
into  the  cavity  of  the  tunica  vaginalis.  Involvement  of  the  epididy- 
mis generally  occurs  during  the  increasing  or  declining  periods  of 
an  acute  urethritis.  Epididymitis  may  be  lateral  or  bilateral,  the 
latter  taking  place  secondary  to  the  invasion  of  the  one  epididymis. 

Etiology. — The  causes  may  be  predisposing  and  exciting.  The 
chief  predisposing  cause  is  gonorrhoea.  The  exciting  causes  are: 
trauma,  e.g.,  from  urethral  instruments  and  irritating  injections. 
Violent  exercise  or  muscular  strain;  seminal  emissions  or  alcoholic 
and  sexual  indulgence.  Transportation  of  the  infective  process  to 
the  epididymis  is  caused  by  the  retroperistaltic  movement  of  the 
vas  deferens. 

Symptoms. — Previous  to  any  definite  symptoms  of  the  inflam- 
matory process  extending  to  the  epididymis,  the  discharge  at  the 
meatus  ceases.  This  sudden  cessation  of  the  secretion  is  therefore 
always  significant.  The  patient  first  experiences  more  or  less  dis- 
4 


50  URETHRITIS. 

comfort  in  the  scrotum  and  groins,  which  soon  becomes  aggravated 
and  severe.  Accompanying  the  pain  he  may  or  may  not  have  con- 
stitutional disturbances;  e.g.,  chills,  fever,  lassitude,  loss  of  appe- 
tite, constipation,  and  a  frequency  of  micturition.  None  of  these 
symptoms  is  pathognomonic  but  simply  points  to  a  general  reaction. 
Physical  examination  of  the  epididymis  will  find  it  to  be  swollen 
and  painful  and  extremely  sensitive  to  touch.  The  scrotal  tissues 
overlying  it  are  in  most  cases  discolored  and  oedematous.  When 
the  globus  minor  is  involved,  primarily  a  small  sized  semilunar 
shaped  or  leech  like  tumor  may  be  distinctly  felt  behind  and  ad- 
herent to  the  testicle.  The  growth  is  comparatively  small,  but  if 
Jhe  body  and  globus  major  (the  head)  are  included,  it  becomes 
quite  large,  often  obscuring  the  testicle  itself.  The  pain  is  de- 
scribed as  being  dull  and  sickening,  continuous,  and  attended  with 
nocturnal  exacerbations.  This  pain  is  aggravated  with  the  least 
movement  of  the  body,  and  in  most  cases  so  intense  for  a  few  days 
as  to  keep  the  patient  in  bed  occasioning  great  annoyance  and  loss 
of  sleep. 

When  the  testicle  becomes  involved  the  condition  is  called  epi- 
didymo-orchitis.  This  is  a  very  frequent  occurrence.  Epididy- 
mo-orchitis  is  always  attended  with  great  swelling  and  effusion,  the 
pain  radiating  into  the  perineum  up  along  the  cord  into  the  groins 
and  down  the  thighs.  Examination  of  the  prostate  and  seminal 
vesicles  will  find  these  organs  slightly  swollen  and  congested,  being 
especially  marked  on  the  corresponding  side  of  the  affected  testicle. 
This  condition  lasts  from  one  to  two  weeks  but  the  climax  of  the 
pain  is  usually  reached  on  the  fourth  or  fifth  day.  Subsequent 
to  a  gonorrhoeal  epididymitis  or  epididymo-orchitis  there  may  be 
more  or  less  induration  which  is  either  temporary  or  permanent. 
Such  an  area  of  chronic  induration  is  fortunately  not  noticeable 
except  to  touch.  The  surface  of  the  indurated  mass  is  usually 
quite  smooth,  whereas  in  tubercular  epididymitis  the  surface  pre- 
sents the  characteristic  nodular  and  uneven  surface. 

Complications  of  Epididymitis. — These  are  mainly  occlusion 
of  the  seminiferous  ducts,  abscess  of  the  testes,  gangrene  of  the 


COMPLICATIONS    OF    POSTERIOR   URETHRITIS.  5 1 

scroturQj  neuralgia  of  the  testicle  (not  common),  and  sometimes 
atrophy  and  hypertrophy,  and  chronic  hydrocele. 

Diagnosis. — Epididymitis  and  epididymo-orchitis  have  been 
mistaken  for  hematocele  of  the  tunica  vaginalis  and  traumatic  or- 
chitis. History  of  a  concomitant  urethral  infection,  swelling,  oedema 
and  redness  of  the  scrotum  and  the  pain  in  the  testicle  will  usually 
furnish  enough  data  to  render  a  diagnosis  easy. 

Prognosis. — In  most  cases  it  is  favorable  where  the  habits  of 
the  patient  are  good,  and  the  treatment  is  efficient.  The  question 
of  sterility  from  the  danger  of  occlusion  of  the  vas  deferens  depends 
whether  one  or  both  sides  are  involved.  When  the  lesion  is  uni- 
lateral and  confined  to  the  head  of  the  epididymis  the  prognosis 
is  always  better.  Examination  of  the  semen  for  spermatozoa  must 
be  made  from  a  number  of  specimens  obtained  at  different  times 
before  the  question  of  sterility  can  be  definitely  settled. 

Treatment. — The  cardinal  factors  in  the  treatment  of  epididy- 
mitis or  orchitis  are:  rest  in  bed,  elevation  of  the  swollen  organ,  and 
hot  or  cold  applications. 

The  remaining  treatment  is  merely  symptomatic.  If  urethral 
injections  have  been  employed  they  must  be  discontinued.  If  there 
is  much  pain  it  should  be  relieved  by  opiates  or  the  application  of 
leeches  along  the  cord.  Lead  water  and  laudanum  is  an  excellent 
application  when  kept  continuously  applied  to  the  part  by  means 
of  a  gauze  dressing,  with  which  it  is  saturated.  The  bowels  should 
be  kept  active,  giving  salines  and  cathartics  if  necessary.  The 
above  measures  are  usually  all  that  are  necessary,  but  other  addi- 
tional methods  have  been  suggested;  e.g.,  withdrawal  of  the  secre- 
tion from  the  cavity  of  the  tunica  vaginalis  by  means  of  a  small 
trocar  or  tenotome.  This  procedure  is  attended  with  great  pain 
and  always  fraught  with  more  or  less  danger  and  is  therefore  to 
be  emphatically  condemned.  Ointments  are  in  many  cases  effi- 
cient in  promoting  absorption,  inducing  resolution,  and  allaying 
pain.  An  excellent  ointment  is  ichthyol  and  lanolin  (25  per  cent). 
Spread  thickly  on  lint  and  cover  the  entire  scrotum.  Another  for- 
mula used  in  the  same  manner  is : 


52  URETHRITIS. 

I^     Unguent  hydrarg, 
■    "         ichthyol, 

"         belladonna  aa 5  ij        ' 

Petrolati  q.  s.  ad §  j. 

Strapping  of  tlie  testicle  is  sometimes  beneficial.  The  scrotum 
is  first  shaved  and  then  encircled  with  strips  of  adhesive  plaster 
about  one  inch  wide.  This  soon  comes  loose,  however,  and  must 
therefore  be  changed  daily. 

Epididymotomy  as  perfected  by  Hagner  is  described  by  him  as 
follows: 

"  At  a  point  over  the  jxmcture  of  the  epididymis  and  testicle  an 
incision  6  to  lo  cm.  long  is  made  through  the  skin  and  parietal 
layer  of  the  tunica  vaginalis.  After  the  serous  membrane  is  opened 
all  the  fluid  is  evacuated  and  the  enlarged  epididymis  examined 
through  the  wound.  The  testicle  with  its  adnexa  is  delivered  from 
the  tunica  vaginalis  and  enveloped  with  warm  towels.  The  epi- 
didymis is  then  examined  and  multiple  punctures  made  through 
its  fibrous  covering  with  a  tenotome,  especially  over  those  portions 
where  the  enlargement  and  thickening  is  greatest.  The  knife  is 
carried  deep  enough  to  penetrate  the  thickened  fibrous  capsule  and 
enter  the  infiltrated  connective  tissue.  When  the  knife  is  through 
the  thickened  covering  of  the  epididymis  a  very  marked  lessening 
of  resistance  will  be  felt.  If  pus  be  seen  to  escape  from  any  of  the 
punctures,  the  opening  is  enlarged  and  a  small  probe  inserted  in 
the  direction  from  which  the  pus  flows,  then  by  a  backward  and 
forward  motion  of  the  probe  the  opening  is  enlarged  and  the  pus 
allowed  to  escape.  By  this  method  there  is  less  danger  of  injuring 
the  tubes  of  the  epididymis  than  by  cutting  with  a  knife.  After 
the  probe  is  passed  in,  pus  will  be  evacuated  by  light  massage  in 
the  region  of  the  abscess  and  a  fine  pointed  syringe  is  used  in  wash- 
ing out  the  cavity  with  i  to  looo  bichloride  of  mercury,  followed 
by  physiological  salt  solution.  The  testis  is  then  restored  to  its 
normal  position,  and  in  every  case  the  tunica  vaginalis  is  thoroughly 
washed  with  i  to  looo  bichloride,  followed  by  normal  salt  solution. 
The  incision  of  the  tunica  vaginalis  is  lightly  closed  with  a  running 


COMPLICATIONS    OF    POSTERIOR    URETHRITIS.  53 

catgut  suture,  a  cigarette  drain  of  gauze  is  then  applied  over  the 
incision,  the  skin  being  brought  together  with  a  subcutaneous  silver 
wire  suture,  the  cigarette  drain  passing  out  at  the  lower  angle  of 
the  wound.  Silver  foil  and  a  sterile  dressing  are  now  applied  and 
the  part  supported  by  a  wide  T  bandage." 

In  every  case  fluid  is  present  in  the  tunica  vaginalis,  varying  in 
amount  from  two  drachms  to  two  and  one-half  ounces. 

One  of  the  most  remarkable  effects  of  this  operation  is  the  very 
rapid  disappearance  of  the  induration  in  both  the  cord  and  the 
epididymis.  The  wounds  are  usually  healed  in  less  than  a  week 
and  unless  rather  carefully  palpated  the  affected  side  would  escape 
notice.  None  of  the  patients  have  had  the  hard  nodular  condition 
of  the  globus  minor  lasting  for  a  long  time,  such  as  persists  so  fre- 
quently in  those  treated  without  operation. 

Taking  an  average  of  the  time  in  which  the  patients  were  up  and 
about  and  entirely  free  from  pain  we  find  it  to  be  five  days.  All 
these  patients  recovered  without  complications;  none  of  them  had 
relapses  and  in  some  of  the  patients  the  improvement  of  the  urethral 
condition  following  the  operation  has  been  very  marked.  We  notice 
so  often  in  gonorrhoeal  epididymitis  treated  medically  that  as  soon 
as  the.epididymitis  improves  the  urethral  discharge  seems  to  increase ; 
this  increase  of  discharge  does  not  occur  in  cases  upon  which 
epdidymotomy  has  been  performed. 

The  advantages  claimed  for  this  operation  are  viz: 

1.  According  to  the  known  pathology,  it  is  a  rational  procedure. 

2.  If  care  be  exercised,  the  danger  to  the  patient  is  slight. 

3.  The  infiltration  of  the  epididymis  disappears  more  rapidly 
under  the  operative  treatment  than  under  any  other. 

4.  The  danger  of  permanent  injury  to  the  testicle  and  epididy- 
mis is  lessened. 

5.  The  patients  are  absolutely  relieved  of  pain  on  recovery  from 
the  anesthetic. 

6.  The  systemic  symptoms  are  promptly  relieved. 

7.  Medicinal  treatment  will  usually  be  followed  only  by  relative 
relief  and  perhaps  not  by  a  permanent  cure,  because  the  infecting 


54  URETHRITIS. 

agent  remains.     And  therefore  the  most  rational  way  to  do  away 
with  this  is  by  incision,  irrigation,  and  drainage. 

Chronic  orchitis  may  succeed  an  acute  attack  or  occurs  in  some 
cases  independent  of  any  other  condition. 

The  exciting  causes  are:  chronic  cystitis,  hypertrophy  of  the 
prostate  gland,  stricture,  and  gonorrhoea. 

If  the  exciting  cause  is  known,  treatment  must  be  directed  thereto. 
It  is  best  for  the  patient  to  remain  in  bed  and  be  given  internally 
potassium  or  sodium  or  sodium  iodide  or  syr.  hydriodic  acid.  If 
this  does  not  answer,  some  mercurials  should  be  ordered:  e.g., 
calomel,  blue  mass,  or  protiodide  of  mercury. 

Congestion  of  the  Prostate. — Acute  congestion  may  occur  as 
one  of  the  complications  in  the  later  stages  of  acute  posterior 
urethritis. 

The  SYMPTOMATOLOGY  is  that  of  a  scA^ere  form  of  posterior  ure- 
thritis. The  patient  will  complain  particularly  of  the  pain  and  the 
sense  of  fullness  in  the  rectum,  perineum,  and  at  the  neck  of  the 
bladder,  sometimes  throbbing  in  character.  The  rectal  and  vesical 
tenesmus  may  be  very  pronounced.  The  urinary  parabulum  is  lost. 
The  swelling  of  the  gland  may  be  so  large  as  to  give  rise  to  straining 
and  frequency  of  urination,  also  some  pain  on  defecation.  This 
may  be  accompanied  by  priapism  and  a  slight  hematuria.  The 
function  of  tirination  when  impaired  always  adds  to  this  distressing 
condition. 

Diagnosis. — Examination  of  the  urine  by  the  two  glass  test  will 
reveal  a  condition  very  much  the  same  as  that  of  posterior  urethritis. 
Rectal  examination  of  the  prostate  will  find  the  organ  considerably 
swollen  or  painful  to  touch,  often  bulging  to  such  an  extent  into  the 
rectum  as  to  impede  the  entrance  of  the  finger. 

Subacute  and  chronic  congestion  of  the  prostate  is  said  to  be 
due  to  mechanical  irritation,  e.g.,  calculi,  passage  of  sounds, 
catheters,  lithotrites,  cystoscopes,  etc.,  and  also  to  stricture.  Sub- 
acute congestion  may  be  likewise  the  result  of  alcoholic  or  sexual 
excesses  and  violent  exercise.  The  condition  may  be  acute,  sub- 
acute, and  chronic.     It  presents  symptoms  resembling  those  of  a 


INFLAMMATION    OF    THE    VERUMONTANUM.  55 

severe  form  of  posterior  urethritis.  The  treatment  is  identical  and 
must  be  vigorously  persisted  in. 

Gonorrhoea  of  the  rectum  is  fortunately  very  rarely  seen  but  a 
patient  thus  affected  may  occasionally  be  found  in  instances  in  which 
sodomy  has  been  practised. 

The  symptoms  at  first  are  those  of  a  mild  degree  of  inflammation 
in  the  rectum,  rendering  defecation  more  or  less  painful  and  soon 
followed  by  a  profuse  serous,  sero-purulent  or  sero-sanguinous  dis- 
charge. These  manifestations  are  liable  to  become  so  severe  and 
aggravated  as  to  cause  considerable  suffering.  Frequency  of 
defecation  is  sometimes  present  and  is  usually  attended  with  con- 
stitutional disturbances.  .  The  objective  symptoms  are  hyperemia 
and  oedema  of  the  mucous  membrane,  and  often  there  may  be  seen 
areas  of  ulceration  about  the  anal  ring.  From  the  anal  orifice 
exudes  a  copious,  thick,  foul  smelling  discharge.  This  affection  is 
more  frequently  met  with  in  women  and  young  boys. 

The  diagnosis  is  as  a  rule  readily  made  unless  obscured  by 
a  misleading  history  on  the  part  of  the  patient.  Microscopic  ex- 
amination of  the  discharge  will  in  itself  prove  conclusively  the 
nature  of  the  infection. 

Prognosis. — With  proper  treatment  and  cleanliness  it  is  always 
favorable. 

Treatment. — The  patient  must  rest  as  much  as  possible,  given 
hot  sitz  baths,  mild  antiseptic  rectal  irrigations,  hot  or  cold,  and  the 
bowels  kept  loose.  If  the  pain  is  severe,  an  opium  or  iodoform 
suppository  will  give  relief.  Unless  the  symptoms  are  very  severe, 
injections  of  about  4  to  8  drachms  nitrate  of  silver  1-5000  to  4000 
directly  into  the  rectum  may  be  given  daily  until  the  condition 
subsides,  and  then  every  second  or  third  day. 

The  mouth  may  also  be  the  seat  of  gonorrhceal  infections,  but  such 
cases  are  exceptionally  rare  and  have  no  definite  symptomatology. 

INFLAMMATION  OF  THE  VERUMONTANUM. 

The  verumontanum  is  located  on  the  floor  or  posterior  surface  of 


S6 


URETHRITIS. 


the  prostatic  urethra.  It  is  marked  by  a  small  peculiar  rounded 
eminence  near  the  top  of  which  is  the  mouth  or  utricle,  and  on  each 
side  of  this  are  the  openings  of  the  ejaculatory  ducts.  On  either 
side  of  the  base  of  this  eminence  are  located  the  openings  of  twenty 
or  thirty  ducts  leading  from  the  prostatic  lobules  and  alveoli.     The 


APPEAiyiNCE  THROUGH  24-F.  TUBE-ACTUAL  SIZE- JOHN  A.HAWKINS 


Fig.  9. — Showing  pathological  deformities  as  seen  through  a  posterior 
urethroscope.     {Hawkins.) 


mucous  membrane  is  distinctly  pale  and  in  marked  contrast  to  the 
other  deep  red  of  the  surrounding  urethra  mucosa. 

The  verumontanum  and  its  contents;  the  utricle  and  ejacula- 
tory ducts  lie  outside  of  the  capsule  of  the  prostate  and  have  a 
distinct  wall  of  their  own. 


GONORRHCEA   IX    THE    FEMALE.  57 

That  the  verumontanum  is  responsible  for  severe  and  often  dis- 
tressing symptoms  generally  classed  as  "prostatic  neuroses,"  was 
probably  first  pointed  out  by  Wossildo,  and  later  by  Hawkins,  who 
made  routine  examinations  of  all  cases  by  means  of  the  deep 
urethroscope. 

Gonorrhoea  is  the  most  frequent  cause  of  inflammation  of  the 
verumontanum  but  it  may  complicate  any  of  the  forms  of  prostatitis 
and  vesiculitis.  The  symptoms  are  neuralgic  pains  in  the  perineum 
and  penis,  testicles,  etc.  The  morning  drop,  frequent  desire  to 
urinate  with  efforts  to  evacuate  another  drop  or  two  after  comple- 
tion of  the  act  is  a  symptom  common  to  many  patients.  Sometimes, 
though  rare,  there  are  precocious  and  painful  ejaculations;  in  other 
cases  tenesmus  with  a  little  blood  in  the  last  drop  of  urine. 

In  the  mildest  cases,  Wossildo  advises  applications  of  tincture  of 
iodine  to  the  verumontanum.  In  the  severe  cases  he  employed  lo 
to  20  per  cent,  silver  nitrate  or  even  the  caustic  stick,  making  direct 
applications  through  the  urethroscope. 

When  the  urethroscope  is  passed,  the  verumontanum  if  intlamed. 
blood  will  soon  ooze  into  the  tube,  or  the  mere  touch  of  a  cotton 
mop  will  induce  slight  bleeding.  Pus  is  frequently  seen  in  the 
mouth  of  the  utricle.  ^ 

Geraghty  has  devised  a  very  simple  instrument  for  making  in- 
jectio'ns  directly  into  the  utricle,  using  a  i  per  cent,  solution  silver  ni- 
trate in  the  beginning  and  increasing  it  to  2  or  3  per  cent.  Too 
strong  a  solution  may  cause  intense  pain  lasting  several  days.  These 
treatments  are  repeated  at  intervals  of  from  5  to  7  days. 

WTien  the  orifice  of  the  utricle  is  small,  Geraghty  recommends 
incision  of  a  wedge-shaped  piece  of  the  roof,  for  the  purpose  of 
drainage.  Young  has  devised  a  scissors  for  this  purpose.  Young 
practises  curettage  of  the  verumontanum  foUo^ang  this  by  direct 
application  of  a  pure  stick  of  nitrate  of  silver. 

GONORRHCEA  IN  THE  FEMALE. 

The  gonococci  may   invade  any  part  of  the  female  genitalia. 


58  URETHRITIS. 

The  morbid  process  may  be  confined  to  the  urethra,  the  os  uteri, 
vagina,  vulva,  Skene's  glands,  Bartholin's  glands,  vestibulo  vaginal 
glands,  and  later  by  continuity  involve  the  uterus,  tubes,  ovaries, 
and  peritoneum.  Gonococci  most  frequently  attack  the  urethra, 
therefore  gonorrhoeal  urethritis  is  the  most  common  affection  met 
with  in  the  female.  The  symptoms  and  pathology  are  very  similar 
to  that  of  the  male,  but  are  ordinarily  less  acute  and  with  tendency  to 
become  chronic.  The  period  of  incubation  is  practically  the  same. 
After  the  first  few  days,  the  acute  stage  develops,  patient  feeling  a 
sense  of  heat  and  burning  in  the  urethra  aggravated  by  urination 
with  increased  frequency  of  urination.  Examination  of  the  tract  will 
find  a  copious  sero-purulent  discharge,  whitish  or  yellowish  green  in 
color,  and  if  this  is  scant  it  may  be  readily  expressed  from  the  meatus 
by  pressure  on  the  floor  of  the  urethra  from  within  outward.  The 
urethral  orifice  will  be  congested,  sensitive,  and  swollen.  Ex- 
amination of  the  urine  by  the  two  glass  test  should  always  be  made 
to  determine  whether  the  badder  is  involved  or  not. 

Chronic  urethitis  in  the  female  is  attended  with  no  subjective 
symptoms  and  is  recognized  only  after  careful  examination.  In 
making  a  diagnosis,  the  orifice  should  be  cleaned  previously  and 
pressure  with  the  finger  made  upon  the  floor  of  the  urethra  from 
behind  forward.  This  must  not  be  done  until  several  hours  after 
the  patient  last  urinated.  A  drop  of  the  discharge  if  present,  con- 
taining the  gonococci,  will  be  expressed  by  this  means.  The 
endoscope  in  these  cases  may  be  used  to  advantage,  by  enabling  one 
to  recognized  the  follicles  of  the  urethra  which  are  sometimes  in- 
volved. These  if  present  will  always  prolong  the  disease.  The 
follicles  near  the  urethral  orifice  are  of  especial  importance  and 
must  be  examined  carefully  for  the  original  focus  of  the  inflamma- 
tion. Chronic  urethritis  in  women  is  as  a  rule  more  easily  cured  than 
in  men,  but  is  often  unrecognized  and  therefore  remains  untreated. 
Chronic  gonorrhoea  in  the  female  is  one  of  the  most  frequent  causes 
of  sterility  and  of  chronic  invalidism. 

Chronic  gonorrhoeal  inflammation  often  may  remain  inactive 
involving  the  same  follicles  of  the  urethra,  or  to  a  vulvo-vaginal 


GONORRHCEA   IN   THE    FEMALE.  59 

gland,  or  to  the  cervix  to  which  may  be  attributed  the  source  of  an 
infection  acquired  from  coitus  with  a  woman  who  presents  no  evi- 
dence of  the  disease.  In  these  same  instances  he  may  have  inter- 
course with  this  person  many  times  before  contact  occurs  with  the 
gonorrhoea!  virus. 

Vaginitis. — This  condition  occurs  in  many  cases  of  acute  gonor- 
rhoea. Microscopical  examination  of  the  vaginal  secretion  is  difficult 
and  often  uncertain,  owing  to  the  fact  that  the  vagina  contains  many 
other  micro-organisms,  including  the  diplococci,  which  it  is  difficult 
to  differentiate  from  the  gonococci.  Culture  tests  should  be  em- 
ployed in  doubtful  cases.  The  secretions  from  the  cervix  and 
urethra  give  the  same  results.  Gonorrhoeal  vaginitis  usually  only 
lasts  from  3  to  5  weeks,  but  has  a  great  tendency  to  recur  at  the  men- 
strual period  or  from  alcoholic  stimulants,  and  to  persist  either  as 
diffuse  chronic  vaginitis  or  in  localized  patches  of  congested,  swollen, 
and  eroded  mucous  membrane. 

Vulvitis. — In  adults  vulvitis  has  not  yet  been  demonstrated 
to  be  gonorrhoeal  in  character.  The  condition  results  from  con- 
tact of  the  surfaces  with  irritating  discharges  from  the  vagina  and  the 
urethra  as  a  result  of  uncleanliness.  This  inflammation  corresponds 
with  balanitis  in  men.  In  children  gonorrhoeal  inflammation  of  the 
vulva  is  more  common.  It  is  sometimes  very  acute  and  the  symp- 
toms severe,  e.g.,  severe  pain,  burning,  and  itching. 

Bartholinitis. — Inflammation  of  the  vulvo- vaginal  glands  is 
most  frequently  caused  by  gonorrhoea  and  when  due  to  such  infec- 
tion either  remains  localized  and  undergoes  involution  or  runs  a 
rapid  course  and  terminates  in  suppuration. 

Chronic  inflammation  of  these  glands  often  complicates  chronic 
gonorrhoea.  The  affected  gland  is  usually  found  as  a  firm,  painless 
nodule;  its  duct  is  dilated  and  reddened.  Pressure  on  the  gland 
usually  causes  the  escape  of  a  mucous  or  muco-purulent  discharge 
which  may  contain  gonococci. 

Inflammation  of  the  Uterus  and  its  Appendages. — Endo- 
metritis of  the  uterine  neck  occurs  commonly  with  acute  gonorrhoea, 
and  the  tubes,  ovaries,  and  the  peritoneum  may  become  secondarily 


6o  URETHRITIS. 

involved.  The  origin  of  the  inflammation  in  these  organs  cannot  ^ 
be  determined  by  the  symptoms  alone,  but  must  be  based  upon  other 
evidences  of  gonorrhoea,  and  by  the  history.  The  gonococcus  is  a 
most  prolific  agent  in  the  production  of  pelvic  inflammatory  con- 
ditions, which  fact  has  been  conclusively  evidenced  by  its  presence 
in  the  pus  of  pyosalpinx  and  in  the  epithelium  and  connective 
tissue  of  the  Fallopian  tubes. 

Treatment. — Thorough  cleanliness  which  is  of  the  utmost 
importance  is  readily  accomplished  by  frequent  douches.  If  the 
condition  is  acute  the  treatment  should  consist  in  rest,  hot  sitz 
baths,  and  hot  or  cold  douches  of  the  vagina.  Hot  irrigations  are 
probably  better,  if  they  can  be  comfortably  borne  by  the  patient. 
Any  of  the  mild  antiseptics,  e.g.,  potassium  permanganate,  1-5000 
to  2000,  boric  acid,  lysol  or  creolin  (1/2:2  per  cent.)  can  be  used  for 
this  purpose.  Dietetic  and  hygienic  treatment  is  the  same  as  that 
for  the  male.  The  discharges  and  mucous  surface  may  be  pre- 
vented from  coming  in  contact  with  the  underclothing  by  the  patient 
wearing  a  piece  of  absorbent  cotton  between  the  folds  of  the  labia, 
held  in  place  by  a  vulva  pad  and  '^T"  bandage.  In  the  stage  of 
decline  when  the  acute  symptoms  subside,  the  douches  may  consist 
of  nitrate  of  silver  i-iooo  to  i-ioo  followed  by  a  daily  application  of 
either  nitrate  of  silver  solution  30  to  40  gr.  to  the  oz.,  or  copper  sul- 
phate 30  to  60  gr.  to  the  oz.,  directly  made  to  the  cervix  and  cervical 
canal.  Tincture  of  iodine  is  also  an  excellent  application  for  keep- 
ing these  parts  clean.  Following  this  a  tampon  of  non-absorbent 
cotton  saturated  with  argyrol  20  per  cent,  should  be  inserted  into  the 
vagina,  or  of  iodoform  and  glycerine,  if  the  patient  does  not  object 
to  the  odor.  When  the  urethra  is  the  seat  of  the  infection  a  swab 
of  cotton  about  two  inches  in  length  on  the  end  of  an  applicator  and 
saturated  with  nitrate  of  silver  (solution  i  to  5  gr.  to  the  oz.)  may 
be  inserted  into  the  urethra  along  its  entire  length  and  left  in  place 
for  3  to  5  minutes.  This  is  a  most  efficient  procedure.  This  treat- 
ment should  be  preceded  by  the  patient's  bladder  being  emptied 
and  the  urethra  irrigated.  Some  authorities  advocate  instillations 
into  the  bladder  with  these  various  antiseptics,  allowing  it  to  remain 


GONORRHOEA   IN   THE    FEMALE.  6 1 

until  the  next  urination.  Involvement  of  Skene's  glands  seen  at 
the  urethral  orifice  or  of  the  glands  of  Naboth  when  found  must 
be  opened  and  treated  according  to  the  principles  of  surgery. 

Bierhoff  outlines  the  various  procedures  which  he  has  employed 
with  success  in  the  abortive  treatment  of  gonorrhoea  in  the  female. 

1.  A  microscopical  examination  of  the    urethral  secretion,   or 
scraping,  and  of  the  secretion  showing  at  the  vulvar  orifice. 

2.  Cleansing  of  the  meatus,  and  irrigations  of  the  urethra  and 
surroundings  with  a  solution  of  1/4  to  1/2  per  cent,  of  protargol. 
Either  the  hand  syringe  or  the  irrigator  may  be  employed,  but  no 
great  degree  of  pressure  should  be  exercised.  In  all  about  150  c.c. 
are  used  for  the  urethra  and  surroundings,  after  which  about  150  c.c. 
of  the  fluid  are  injected,  through  the  urethra,  into  the  bladder,  to  be 
later  expelled  by  the  patient.  In  this  latter  irrigation,  the  patient 
is  instructed  to  relax  the  muscles,  as  though  about  to  urinate,  when 
the  urethra  feels  distended,  whereupon  the  fluid  will  be  found  to  flow 
easily  into  the  bladder. 

3.  Cleansing  of  the  vulva  with  150  c.c.  of  the  solution. 

4.  A  vaginal  scraping  is  now  made  and  examined,  the  sterilized 
platinum  loop  being  passed  well  into  the  vagina  for  this  purpose. 

5.  The  nozzle  of  the  syringe  is  gently  inserted  into  the  vagina,  the 
stream  of  the  solution,  during  this  time,  passing  into  the  vagina, 
and  the  nozzle  passed  up  to  the  point  where  the  body  of  the  syringe 
blocks  the  outlet.  The  syringe  blocking  the  outlet  to  prevent  the 
escape  of  the  injected  fluid,  the  injection  is  continued  until  the 
vagina  becomes  distended  with  this  solution,  which  is  then  allowed 
to  flow  out.  About  300  c.c.  of  the  solution  are  used  for  this  vaginal 
cleansing. 

6.  A  sterilized  speculum  is  inserted  into  the  vagina — preferably 
of  the  duckbifl  type — and  the  vagina,  particularly  the  f  ornices  and 
the  cervical  orifice,  cleansed  by  gently  vnping  with  little  cotton 
pledgets. 

7.  A  specimen  of  the  cervical  secretion,  or  a  scraping  from  the 
cervical  canal,  is  now  made  with  the  sterilized  loop,  and  a  micro- 
scopical examination  thereof  made.     Should  this  be  found  to  be 


62  URETHRITIS. 

free  of  gonococci,  and  to  contain  few  or  no  blood  corpuscles  what- 
ever, thfen  the  vagina  is  lightly  tamponed  with  several  yards  of 
narrow,  absorbent  gauze  strips,  saturated  in  i  per  cent,  protargol 
solution,  and  the  speculum  withdrawn.  He  employs  the  tamponade 
whether  the  vagina  is  infected  or  not.  If  it  be  infected,  he  employs 
a  5  per  cent,  solution.  There  is  then  an  exfoliation  of  the  super- 
ficial epithelial  layers,  and  usually,  in  from  twenty-four  to  forty- 
eight  hours,  the  vaginal  secretion  will  be  found  to  be  sterile.  If  the 
vagina  be  not  infected,  its  infection  is  prevented  by  this  tamponade. 

8.  A  soluble  urethral  bougie  of  5  per  cent,  protargol  in  cacao 
butter,  made  of  a  length  of  an  inch  and  a  half,  is  inserted  into  the 
urethra  and  left  therein. 

9.  While  the  index  finger  of  the  left  hand  maintains  the  urethral 
bougie  in  place  by  pressure  of  the  finger  against  the  meatus,  a  pad 
of  absorbent  cotton,  saturated  with  i  per  cent,  protargol  solution, 
is  placed  over  the  urethral  and  vulvar  orifices  and  kept  in  place 
with  a  "T"  binder.  As  the  patient  has  urinated  in  emptying  the 
bladder  of  the  fluid  injected  into  it,  she  is  now  instructed  to  resist 
the  desire  to  urinate,  if  possible,  for  several  hours,  so  that  the  drug 
in  the  melting  bougie  may  be  kept  in  contact  with  the  urethral 
mucous  membrane  for  as  long  a  period  as  possible.  The  pad  cov- 
ering the  vulva  is  also  kept  moist  with  the  i  per  cent,  protargol 
solution. 

10.  Rest  in  bed,  if  possible,  is  of  advantage  in  the  treatment. 
Bland  diet  should  be  ordered;  all  intoxicating  or  carbonated  drinks 
avoided,  and  all  highly  spiced  articles  of  food  omitted  from  the 
dietary.  A  daily  warm  sitz  bath,  in  the  evening,  completes  the 
treatment.  The  tampon  is  left  in  place  for  twenty-four  hours, 
whereupon  it  is  removed  by  the  physician,  and  the  treatment,  as 
outlined,  repeated.  Should  the  patient  desire  to  urinate,  the  moist 
pad  is  simply  removed,  to  be  replaced  at  once  thereafter.  Under 
this  treatment,  within  twenty-four  to  forty-eight  hours,  if  treatment 
is  to  prove  a  success,  the  urethral  secretion  must  be  free  of  gono- 
cocci,  as  must  also  the  vulvar  and  vaginal  scrapings.  After  two 
such  applications,  if  there  be  no  more  gonococci  present,  it  is  his 


GONORRHOEA    IN    THE    FEMALE.  6 


o 


custom  to  begin  the  tests  by  omitting  entirely  the  urethral  irriga- 
tion and  bougie,  and  by  substituting  a  vaginal  irrigation  of  bichlo- 
ride of  mercury  solution,  i  to  4000,  or  a  solution  of  1/2  per  cent, 
zinc  sulphocarbolate  for  the  irrigation  with  protargol,  and  the  vagi- 
nal tampon  is  entirely  omitted.  The  warm  sitz  baths  are,  how- 
ever, continued  for  a  few  days  longer.  Should  the  test  of  the  in- 
terruption of  treatment  be  followed  by  no  return  of  gonococcus- 
bearing  secretion,  then  we  proceed  to  the  alcohol  test.  Further 
control  examinations  must  be  made  at  intervals,  and  only  when 
the  urethral  and  cervical  scrapings  continue  free  of  gonococci,  even 
after  the  next  following  menstruation,  may  we  discharge  the  pa- 
tient as  definitely  cured.  Should  discharge  with  gonococci  reap- 
pear during  the  tests,  then  we  simply  continue  with  the  treatment 
until  the  patient  is  cured. 

Treatment  of  Acute  Bartholinitis. — Absolute  rest  is  essential 
and  the  application  of  hot  fomentations.  If  resolution  does  not 
occur  and  the  process  terminates  in  suppuration,  the  condition  is  one 
that  assumes  surgical  importance.  Further  complications,  e.g., 
endometritis,  salpingitis,  or  pyosalpinx  and  involvement  of  the 
ovaries  must  be  treated  according  to  the  principles  of  gynecology. 
The  constitutional  treatment  consists  in  giving  oil  of  sandalwood, 
cubebs  and  copaiba,  or  these  three  in  combination  (formula  same 
as  that  given  in  the  chapter  on  treatment  of  gonorrhoea  in  the  male, 
q.  v.). 

Involvement  of  the  vulva  is  often  attended  with  considerable 
itching  and  burning  which  may  be  relieved  by  hot  sitz  baths,  lead 
water  and  laudanum  solutions,  and  later  when  the  symptoms  begin 
to  subside  the  part  may  be  touched  with  i  per  cent,  solution  nitrate 
of  silver  5  to  20  gr.  to  the  oz.  and  later  copiously  dusting  the  area 
with  boric  acid  and  talcum  powder. 


CHAPTER  III. 

AFFECTIONS  OF  THE  PENIS. 

PHIMOSIS. 

Phimosis  is  a  condition  of  abnormal  narrowing  of  the  preputial 
orifice  in  which  retraction  of  the  foreskin  is  either  difhcult  or  im- 
possible.    The  foreskin  may  or  may  not  be  redundant. 

Varieties. — Congenital  and  acquired. 

The  congenital  form  is  in  most  cases  adherent  to  the  glans. 

Acquired  phimosis  is  usually  the  result  of  inflammatory  or  cica- 
tricial contraction  from  co-existent  lesions  or  urethritis. 

Results. — Recurrent  attacks  of  balanitis,  venereal  warts,  and 
herpes  progenitalis.  Induces  masturbation  in  very  early  life,  in- 
creased susceptibility  to  infections  and  premature  ejaculations.  In 
infants,  reflex  nervous  phenomena,  e.g.,  convulsions,  restlessness, 
and  enuresis. 

Treatment. — By  circumcision.  In  infants,  one  to  four  weeks 
old,  the  foreskin  should  be  separated  from  its  adhesions  and  re- 
moved by  one  sweep  of  the  knife.  No  anaesthetic  is  necessary  and 
hemorrhage  and  pain  are  slight.  Circumcision  in  congenital  phi- 
mosis of  older  children  and  adults,  the  technic  is  as  follows:  (See 
Figs.  lo,  II,  12,  and  13).  The  field  is  rendered  aseptic,  excessive 
hair  removed,  etc.,  parts  are  cocainized  with  i  or  2  per  cent,  solu- 
tion, or  ether  may  be  used  as  a  general  anaesthetic.  The  foreskin 
is  then  brought  well  forward  with  a  pair  of  haemostats,  one  above, 
and  the  other  below.  (Fig.  10.)  The  tissues  are  drawn  sHghtly 
tense  and  the  circumcision  forceps  applied,  lengthwise  and  parallel 
to  the  body  of  the  patient.  The  overlying  skin  is  then  quickly 
severed,  the  clamps  removed,  and  the  tissues  relaxed.  The  next 
step  is  to  divide  the  mucous  membrane  on  the  dorsum  with  a 

64 


PHIMOSIS. 


65 


median  incision — down  to  the  coronary  sulcus.     The  two  sides  are 
then  trimmed  down  to  about  i  /  4  inch  encircling  the  penis.    All  bleed- 


FiG.   10. — Excision  of  the  prepuce. 


Fig.   II. — Dorsal  incision  of  the  mucous  membrane.     (After  Veau.) 

ing  vessels  are  tied.     The  cut  margins  of  the  skin  and  mucous 
membrane  are  then  apposed,   and  held  together  with  as  many 

5 


66 


AFFECTIONS    OF    THE    PENIS. 


sutures  (silk  or  catgut)  as  may  be  necessary.  The  subsequent 
dressings  should  consist  of  sterile  gauze  kept  continuously  moist 
with  lead  water  and  laudanum  or  sublimate  solution.  Tnese  dress- 
ings should  be  frequently  changed. 


Fig.     12. — Trimming  the   mucous    mem- 
brane.    {After  Veau.) 


Fig.    13. — Suturing  the  edges. 


PARAPHIMOSIS. 

Paraphimosis  is  an  affection  in  which  the  prepuce  is  drawn  forci- 
bly back  over  the  glans  where  it  contracts  and  the  patient  is  unable 
to  effect  its  return,  a  typical  case  of  which  is  shown  in  the  accom- 
panying illustration.     (Fig.  14.) 

Causes. — Pre-existing  of  phimosis,  forcible  or  excessive  coitus, 
lymphangitis,  traumatism,  intrapreputial  lesions,  e.g.,  chancre, 
vegetations,  chancroids,  balanitis,  etc. 

Treatment. — The  dangers  attendant  upon  imprudent  delay 
in  instituting  measures  for  the  immediate  relief  of  paraphimosis 


PARAPHIMOSIS. 


('1 


are  so  imminent  that  the  importance  of  a  proper  understanding  of 
the  management  of  these  cases  cannot  be  emphasized  too  forcibly. 
Whatever  the  causal  factor  may  be,  paraphimosis  is  primarily 
the  consequence  of  a  deformity,  or  the  terminal  condition  of  a 
pre-existent  phimosis.     The  narrowed  preputial  meatus  for  some 


Fig.   14. — Paraphimosis. 

purpose  is  drawn  forcibly  back  over  the  glans  to  the  corona  sulcus, 
where  it  contracts,  and  becomes  imbedded  at  this  point.  The 
patient  then  suddenly  discovers  his  inability  to  cause  the  glans  to  re- 
enter the  foreskin.  The  obstruction  thus  occasioned  causes  a  me- 
chanical disturbance  of  the  circulation  to  the  part,  thereby 
interfering  with  the  venous  return,  and  there  rapidly  ensues  a  transu- 
dation of  the  serum  into  the  tissues.     The  penis  is  constantly  in_ 


68 


AFFECTIONS    OF   THE   PENIS. 


creased  in  size,  until  by  contraction,  it  may  become  tortuous  and 
twisted. 

After  every  effort  toward  reducing  it  meets  with  failure,  the  patient 
becomes  alarmed,  and  he  seeks  to  obtain  relief,  and  it  is  this  ex- 
tremely painful  and  lamentable  condition  with  which  the  surgeon  is 
not  uncommonly  confronted.  It  is  obvious,  therefore,  that  if  this 
stage  of  affairs  is  not  radically  dealt  with,  gangrene  must  quickly 
develop.  This  sequel  is,  fortunately,  a  rare  occurrence,  owing  to  the 
timely  intervention  of  nature,  in  her  effort  to  overcome  the  constric- 
tion, emancipating  the  glans  finally,  by  destruction  of  the  unyield- 


FiG.    IS. — Reduction  of 
paraphimosis. 


Fig.   1 6. — Reduction    of    paraphimosis.      (Am. 
Text  Book  G.  U.  Dis.) 


ing  tissue,  in  the  process  of  sloughing.  Thus  we  have  a  condition 
which  is  almost  invariably  followed  by  secondary  infection,  in  which, 
if  there  is  any  tendency  to  phagedena,  it  may  go  so  far  as  to  result 
in  penile  fistulae.  Accompanying  lesions,  chancroidal  or  specific, 
are  always  ominous  for  this  reason.  Under  such  conditions  the 
treatment  is  somewhat  accordingly  modified.  Clinically,  para- 
phimosis may  be  classified  into  two  types,  the  reducible  and  the  irre- 
ducible. 

The  reducible  yields  to  manipulation,  bimanually;  in  the  irre- 
ducible, surgical  intervention  is  necessary. 

In  the  first  class  of  cases,  reduction  is  often  effected  by  expressing 


PARAPHIMOSIS.  69 

the  prepuce  over  the  corona  glans.  This  is  accomplished  by  grasping 
the  everted  preputial  margin,  laterally,  simultaneously  exerting 
judicious  pressure  and  manipulation  to  the  glans,  and  thus  freeing 
from  the  contracting  band,  and  slipping  it  back  into  the  orifice,  as 
shown  in  figures  1 5  and  16.  Should  this  prove  unsuccessful,  attempt 
should  be  made  by  encircling  the  penis  with  the  fingers  of  one  hand, 
and  making  firm  concentric  pressure  just  below  the  unyielding  ring, 
felt  to  be  hard  and  indurated.  With  the  other  hand,  taxis  to  the 
glans  should  be  made.  These  methods  may  be  facilitated  by  a 
dusting  powder  of  equal  parts,  boracic  acid  and  lycopodium,  freely 
sprinkled  over  the  part  to  enable  a  firmer  hold.  This  is  more  com- 
mendable than  the  use  of  a  lubricant.  Once  reduced,  subsequent 
care  should  consist  in  the  application  of  lead  water  and  laudanum, 
for  24  to  48  hours,  and  constitutionally  a  sedative,  e.g.,  sodium  or 
potassium  bromid. 


Fig.   17. — Division  of  paraphimosis.     (Am.  Text  Book  G.  U.  Dis.) 

Dorsal  Incision. — In  cases  of  the  second  type,  in  which  the  degree 
of  contraction  is  extreme  the  condition  assumes  a  surgical  aspect, 
and  it  is  necessary  to  divide  the  constricting  ring  by  a  dorsal- 
incision  on  the  median  line,  as  illustrated  in  Fig.  17.  No  time  should 
be  lost  in  its  performance  when  other  measures  fail.  The  patient 
may  be  anaesthetized,  using  ethyl  chlorid,  nitrous  oxid,  or  ether. 
The  part  is  rendered  thoroughly  aseptic.  If  there  be  coexistent 
lesions  they  should  be  carefully  touched  with  pure   carbolic  acid. 


70  AFFECTIONS    OF    THE    PENIS. 

Cocain  or  eucain,  i  or  2  per  cent,  may  under  some  circumstance  be 
used  subcutaneously,  if  the  patient  consents,  and  it  is  advantageous 
when  expedition  is  desired.  A  curved  pointed  bistoury  or  straight 
tenotome,  pair  of  straight  scissors,  and  a  few  hemostats  are  all  the 
instruments  required.  After  dividing  the  band  it  is  w^ll  to  make 
sure  of  its  completeness  by  easily  drawing  the  prepuce  over  the  glans. 
The  whole  procedure  may  be  rendered  bloodless  by  improvising  a 
tourniquet  with  a  simple  twist  of  a  catheter  at  the  base  of  the 
penis.     Subsequent  bleeding  may  be  controlled  by  pressure. 

In  specific,  or  even  suspicious  cases  it  is  best  to  allow  healing  to 
take  place  by  granulation,  instead  of  apposing  the  incised  edges, 
thus  allowing  better  access  to  the  part  in  the  event  of  secondary 
infecti(5n.  Under  such  circumstances,  the  dressing  par  excellence 
is  iodoform,  used  copiously  as  a  dusting  powder  or  upon  gauze, 
loosely  packed  between  the  glans  and  the  inner  tegument  of  the 
foreskin.  Dry  sterile  gauze  should  subordinate  this  dressing,  and 
then  by  means  of  a  T  bandage  the  penis  should  be  held  vertically 
and  against  the  pubes,  thus  minimizing  the  blood  tension  and  giving 
comfort  to  the  patient.  If  possible,  he  should  be  kept  in  bed  for  a 
few  days. 

The  subsequent  treatment  is  of  signal  importance.  The  dressing 
should  be  changed  every  24  hours,  the  desiccated  blood  and  pus 
removed  by  a  spray  of  hydrogen  dioxid;  and  the  penis  immersed 
in  a  hot  solution  of  potassium  permanganate,  1-2000  for  about  five 
minutes.  If  there  is  any  tendency  to  suppuration,  gently  apply  by 
means  of  a  cotton  swab  25  per  cent,  solution  nitric  acid,  or  acid 
mercuric  nitrate  solution  (10  per  cent.),  previously  cocainizing  the 
surface  to  be  touched.  Again  dress  wdth  iodoform,  or,  if  the  patient 
objects  to  its  odor,  iodomuth,  or  thymiodide  are  invaluable  substi- 
tutes. In  cases  complicated  with  verruca,  the  growths  should  be 
immediately  removed,  as  these  are  not  infrequently  the  primary 
cause  of  this  condition.  Yeiy  often  cases  of  paraphimosis  are  seen 
in  which  the  chief  obstacle  preventing  reduction  is  simply  the  accom 
panying  oedema  which  may  be  readily  overcome  by  making  multiple 
punctures  over  the  oedematous  folds,  thus  at  once  mitigating  the 


HERPES     PROGENITALIS.  71 

degree  of  constriction.     This  in  itself  may  be  the  means  of  effecting 
relief. 

BALANITIS  AND  BALANO-POSTHITIS. 

Balanitis  or  inflammation  of  the  mucous  membrane  covering 
glans  penis. 

Posthitis  is  an  inflammation  of  the  mucous  membrane  of  the  pre- 
puce.    Balano-posthitis  includes  both  conditions. 

Causes. — Phimosis,  filth,  chancroids,  urethritis,  gout,  and  lithe- 
mia,  bacteria,  diabetes,  syphilis. 

Symptoms. — Heat,  burning,  and  itching  of  the  glans  and  pre- 
puce; soon  this  is  followed  by  the  part  being  more  or  less  excori- 
ated and  ulcerated  with  a  copious  offensive  cream  discharge.  The 
tissues  will  be  tender,  oedematous,  and  congested. 

Diagnosis. — Must  be  differentiated  from  urethritis,  chancre,  and 
chancroid. 

Urine. — Two  glass  test  should  be  made  to  determine  whether 
or  not  there  is  an  accompanying  urethritis. 

Treatment. — The  prepuce  should  be  gently  retracted  if  possible 
or,  if  not,  superputial  infections  and  bathed  in  mild  hot  antiseptic 
solutions.  It  is  then  dried,  the  surfaces  touched  with  cupric  sulph. 
solution  (lo  grs.  to  the  oz.)  and  dusted  v/ith  stearate  of  zinc  or 
preparations  of  calomel  and  bismuth,  boric  acid,  etc.  Lotio  Nigre 
kept  on  a  thin  layer  of  absorbent  cotton  continuously  moist  inter- 
posed between  the  two  mucous  membranes  is  also  an  excellent  dress- 
ing.    Circumcision  should  then  be  advised  to  prevent  recurrences. 

HERPES  PROGENITALIS. 

These  occur  in  the  form  of  small  vesicles  in  distinct  groups,  situ- 
ated upon  an  erythematous  base  of  the  skin  or  mucous  membrane 
of  the  prepuce.  They  tend  to  ulcerate,  but  are  of  short  duration 
and  recur,  periodically,  seldom  attended  with  any  pain. 

Cause. — Not  definitely  understood,  but  may  be  predisposed  by 
sexual  excesses,  phimosis,  balano-posthitis,  and  gouty  diatheses. 


72  AFFECTIONS    OF   THE   PENIS. 

Diagnosis. — The  history  of  the  existence  of  any  of  these  causa- 
tive factors,  of  frequent  recurrences,  and  the  punched  appearance 
of  the  ruptured  vesicles  are  sufficient  to  render  their  recognition 
easy. 

Treatment. — Removal  of  cause  if  ascertained,  absolute  cleanli- 
ness, and  dusting  powder  of  stearate  zinc  are  usually  all  that  are 
necessary  to  effect  a  cure.  In  most  cases  circumcision  should  be 
advised. 

PAPILLOMATA. 

Synonyms. — ^Venereal  warts,  verruca,  vegetations. 

Papillomata  are  simply  warty  excrescences.  They  are  cauli- 
flower in  appearance  and  are  seen  most  commonly  on  the  corona 
sulcus.  They  arise  as  a  result  of  irritating  discharges  or  from 
friction  with  adjacent  surfaces.  Pathologically  these  growths  con- 
sist of  hypertrophic  changes  of  the  papillary  layer. 

Diagnosis. — Must  not  be  confounded  with  syphilitic  condylo- 
mata and  epithelioma. 

Treatment. — The  measures  for  removing  these  warts  are  both 
surgical  and  medical.  Circumcision  should  be  performed  if  they 
are  on  the  foreskin.  Otherwise  the  growths  if  small  may  be  touched 
with  some  mild  acid,  lactic  acid  preferably.  If  this  is  not  effect- 
ive remove  them  at  the  base  with  a  sharped  curved  on  the  flat 
scissors,  and  touch  the  floor  with  lactic  acid.  The  Paquelin  cautery 
may  be  used  to  control  the  bleeding. 

CARCINOMA  OF  THE  PENIS. 

Malignant  warts  commonly  begin  in  the  form  of  a  venereal  wart 
and  in  other  instances  as  a  simple  nodule  or  excoriation.  This 
temporarily  remains  indolent  or  soon  progresses  toward  degener- 
ative changes. 

Causes. — ^Predisposing  malignant  conditions  are  the  age,  redun- 
dant and  uncircumcised  foreskin,  chronic  balano-posthitis,  and  filth, 
etc.    It  may  arise  as  a  result  of  extension  from  contiguous  structures. 


CARCINOMA    OF    THE    PENIS.  73 

Diagnosis. — In  individuals  past  middle  life,  growths  about  the 
genitalia  should  always  be  regarded  with  suspicion  and  the  nature 
of  it  must  be  clearly  proven  by  the  microscope.  It  may  be  differ- 
entiated from  gummata  by  observing  the  effects  of  mixed  antisyphi- 
litic  treatment.  Phagedenic  chancroids  may  often  be  confounded 
with  malignant  growths  on  the  penis. 

Prognosis. — Operative  treatment  is  imperative.  Early  ampu- 
tation of  the  penis  with  extirpation  of  the  glans  in  the  groin  is,  in 
most  instances,  followed  by  a  permanent  cure. 

Treatment. — Partial  or  complete  amputation. 

Technic  of  Partial  Amputation. — A  catheter  or  sound  is  passed 
into  the  urethra  for  most  of  its  length.  A  tourniquet  is  then  applied 
at  the  root  of  the  penis.  The  healthy  skin  wide  of  the  growth  is 
cut  through  with  a  circular  sweep  of  the  knife,  and  turned  back  an 
inch.  The  corpora  cavernosa  is  divided  down  to  the  corpora  spon- 
giosum, which  with  the  urethra  is  left  to  project  for  about  an  inch. 
This  is  then  cut  through  above  and  below.  The  tourniquet  is  re- 
moved, bleeding  vessels  are  carefully  tied,  and  the  cutaneous  mar- 
gins and  the  mucous  membrane  of  the  urethra  brought  together 
by  firm  medium-sized  catgut  sutures. 

A  catheter  is  allowed  to  remain  in  place  so  as  to  protect  the 
dressings  from  being  soiled  by  the  urine. 

Complete  Extirpation. — This  includes  the  removal  of  the  penis 
down  to  its  root,  also  the  inguinal  and  crural  lymphatic  ganglion. 
The  operation  is  as  follows:  The  scrotum  is  divided  into  two  halves 
by  an  incision  along  the  entire  line  of  the  raphe  back  as  far  as  the 
corpus  spongiosum.  A  sound  bougie  is  passed  into  the  urethra 
for  about  two-thirds  of  its  length  and  held  vertically  by  an  assistant. 
The  corpus  spongiosum  is  carefully  separated  about  as  far  back 
as  the  triangular  ligament,  wide  of  the  diseased  area.  The  bougie 
is  then  withdrawn,  the  urethra  is  then  divided  and  carefully  dis- 
sected out.  All  bleeding  vessels  are  ligated.  The  principal  blood 
vessel  encountered  in  this  operation  is  the  dorsal  artery  of  the  penis. 
An  incision  now  is  made  encircling  the  penis  at  its  root,  on  either 
side  up  to  the  central  incision  below.     The  suspensory  ligament  is 


74  AFFECTIONS    OF   THE   PENIS. 

then  cut  through  and  the  crus  detached  from  the  rami  of  the  pubes. 
The  urethra  is  now  slit  up  vertically  and  stretched  to  the  lower 
angle  of  the  wound  in  the  scrotum. 

The  subsequent  treatment  involves  frequent  dressing,  strict 
observance  of  every  antiseptic  precaution,  and  continuous  drain- 
age of  the  urine  by  means  of  a  small  soft  rubber  catheter. 

The  testicle  may  in  some  cases  be  removed  for  the  purpose  of 
ridding  the  patient  of  any  future  sexual  desire.  The  urethra  in  such 
instances  is  sutured  to  the  lower  angle  of  the  wound  in  the  perineum. 

SARCOMA. 

May  occur  on  the  penis  and  are  usually  the  result  of  secondary 
involvement  of  other  parts. 

Symptoms  and  treatment  are  practically  the  same  as  in  carcinoma. 

HYPOSPADIAS. 

This  condition  is  quite  commonly  seen  and  consists  in  a  congenital 
deficiency  of  the  corpus  spongiosum  and  floor  of  the  urethra  (see 
Plate  I) .  A  distinction  has  been  made  as  to  the  location  of  this  de- 
fect. When  it  occurs  at  the  end  of  the  urethra  just  at  the  base  of  the 
glans  it  is  termed  balanic  hypospadias  and  anywhere  between  this 
point  and  the  penoscrotal  junction  it  is  termed  perineal  hypospadias. 
(Fig.  i8.)  The  urine  is  ejected  through  the  abnormal  opening  but 
otherwise  the  function  is  not  impaired. 

Treatment. — In  most  instances  operative  treatment  for  these 
conditions  is  not  necessary,  unless  the  function  of  the  part  is  im- 
paired. Plastic  operations  when  skillfully  performed  will  relieve 
the  condition,  but  should  never  be  done  upon  infants.  The  child 
should  be  at  least  ten  years  old,  and  even  then  its  results  are 
uncertain. 

EPISPADIAS. 

This  condition  is  practically  the  same  as  hypospadias,  in  that  there 


JUXTA-URETHRAL    SINUSES. 


/O 


is  an  absence  or  deficiency  of  the  urethra,  but  involves  the  upper 
surface  of  the  urethra.  This  affection  is  much  more  rare  and  is 
always  congenital. 

Treatment. — The  plastic  operations  of  Thiersch  and  Dolbeay 
and  Beck  may  be  performed  after  the  tenth  year. 


Fig.    i8. — Perineal  hypospadias.      (Am.  Text  Book  G.   U.  Dis.) 


JUXTA-URETHRAL  SINUSES. 


This  affection  complicating  gonorrhoea  is  very  commonly  the 
source  of  a  persistent  discharge  from  the  meatus  and  unless  a  very 
careful  examination  of  both  lips  is  made,  may  be  frequenth'  over- 
looked. Juxta-urethral  sinuses  usually  appear  in  the  middle  of  the 
lip  of  the  meatus  on  one  or  both  sides.  They  run  parallel  with  the 
urethra  and  often  communicate  with  it  by  a  fistulous  opening  into 


76  AFFECTIONS    OF    THE    PENIS. 

the  fossa  navicularis.  These  infecting  sinuses  may  repeatedly  be 
the  source  of  auto-infection  or  may  even  inoculate  the  female  coming 
in  contact. 

Treatment. — An  attempt  to  obliterate  the  sinus  by  the  injection  of 
a  drop  of  nitrate  of  silver  solution  15  gr.  to  the  oz.  previously  cleans- 
ing the  part  and  then  introducing  the  irritant  by  means  of  a  blunt 
needle  and  hypodermic  syringe.  When  this  is  unsuccessful,  it  must 
be  laid  open  by  an  incision  along  its  entire  length  with  a  very  small 
tenotome  and  then  touched  with  stimulating  agents  each  day  and 
allowed  to  granulate  from  below.  Sometimes  the  sinuses  may  be 
obliterated  by  the  quick  introduction  and  immediate  withdrawal 
of  a  thin  red  hot  wire.  This  is  always  attended  with  great  pain,  and 
rarely  successful. 

PERIURETHRAL  ABSCESSES. 

Periurethral  phlegmon  may  occur  anywhere  along  the  course  of 
the  urethra  as  far  back  as  the  bulb.  They  usually  begin  as  a 
small  nodule,  slightly  tender,  and  increasing  gradually  or  rapidly  in 
size  and  eventually  form  an  abscess.  This  may  be  unilateral  or 
bilateral  and  round  or  globular  in  shape.  The  act  of  urination  is 
usually  interfered  with  more  or  less,  as  they  increase  in  size. 

The  crypts  of  Morgagni  or  the  follicles  of  the  glands  of  Littre 
are  often  the  seat  of  the  infiltration  of  inflammatory  exudate.  These 
are  felt  at  first  as  small  shot-like  bodies  in  the  substance  of  the  corpus 
spongiosum.  It  is  most  frequently  seen  in  the  subacute  stages  or 
after  the  cure  of  gonorrhoea.  This  deposit,  however,  in  many  in- 
stances is  the  beginning  of  an  abscess,  and  the  danger  of  urethral 
fistulae  is  imminent.  As  the  process  of  suppuration  goes  on,  the 
swelling  and  inflammation  increase  and  when  the  abscess  cavity 
is  opened  it  is  often  found  to  contain  several  drachms  of  pus. 

Sometimes  these  threatened  abscesses  undergo  resolution  which 
may  or  may  not  leave  a  nodule  as  the  focus.  They  recur  upon  the 
least  indiscretion,  consequently  they  are  a  frequent  source  of 
annoyance  and  menace  to  the  comfort  of  the  patient.  When 
fistulae  are  formed  a  plastic  operation  is  necessary. 


ABSCESS    OF    COWPER  S    GLAND.  77 

ABSCESS  OF  COWPER'S  GLAND. 

Suppurative  cowperitis  most  frequently  occurs  during  the 
stage  of  decline  of  gonorrhoea  or  later.  The  involvement  may  be 
unilateral  or  bilateral.  They  are  peculiar  in  that  they  are  seated  on 
either  side  of  the  raphe,  at  about  the  penoscrotal  junction,  or  slightly 
posterior  to  it. 

The  S5miptoms  are  pain  and  a  feeling  of  heaviness  and  tension 
in  the  perineum,  or  in  the  region  of  the  bulb,  which  is  made  worse 
by  sitting,  or  in  walking.  These  symptoms  may  become  quite 
severe  and  are  accompanied  by  chills,  fever,  and  malaise,  sometimes 
dysuria  and  retention  from  pressure.  Examination  of  the  part 
finds  it  a  tense,  swollen,  red  mass  pointing  forward  on  both  sides  of 
the  median  line.  Should  the  abscess  become  very  large  the  peri- 
neum will  also  become  red,  oedematous,  and  swollen. 

Cowperitis  may  be  acute,  chronic,  or  suppurative. 

Treatment. — In  the  inflammatory  stage  lead  water  and  lauda- 
num or  cold  applications  to  the  part  often  give  relief.  Soon  as 
suppuration  occurs  and  fluctuation  is  noticed,  a  free  incision  should 
be  made  over  the  abscess,  its  contents  thoroughly  evacuated,  irri- 
gated with  warm  bichloride  solution  1-2000,  or  normal  salt  solu- 
tion, and  then  packed  with  iodoform  and  sterilized  gauze.  Fistulae 
very  rarely  develop  as  a  result  of  cowperitis. 

PRIAPISM. 

Priapism  is  a  condition  in  which  there  is  an  involuntary  and  per- 
sistent erection  of  the  penis  minus  sexual  desire — resulting  as  a  rule 
from  such  causes  as: — inflammatory  swelling  of  the  penis,  haema- 
toma,  phimosis,  vesical  calculus,  stricture,  and  more  rarely  leukemia 
and  gout.  The  lesion  may  be  in  the  upper  portion  of  the  spinal 
cord.     Excessive  or  violent  coitus  may  also  be  a  causative  factor. 

The  erection  often  originally  begins  with  some  sexual  desire  soon 
becoming  obstinate.  It  appears  suddenly  and  persists  for  weeks 
and  even  months.  The  condition  is  generally  painful  and  the  act 
of  urination  is  impaired. 


78  "  ArrECTIONS    OF    THE    PENIS. 

Treatment. — Nervous  sedatives,  e.g.,  sodium  or  potassium  bro- 
mide, morphia,  etc.,  should  be  given.  Cold  applications  are  often 
beneficial  in  allaying  the  pain.  Incisions  into  the  corpora  caver- 
nosa may  also  be  advised.  Some  severe  cases  of  priapism  are  fol- 
lowed by  impotence,  which,  if  possible,  should  be  averted. 

Neuralgia  of  the  penis  is  of  the  reflex  type  and  is  caused  by 
some  vesical  or  pelvic  disease.  Persons  of  gouty  diatheses  are  also 
prone  to  this  affection. 

Tumors. — Besides  papillomata  of  the  penis  there  may  be  found 
other  growths  of  both  the  benign  and  malignant  type.  The  be- 
nign tumors  occurring  most  commonly  on  the  penis  are:  chondro- 
mata,  osteomata,  angioma,  sebaceous  and  dermoid  cysts.  Sarcoma 
and  carcinoma  represent  the  malignant  tumors.  Carcinoma  of  the 
penis  is  by  far  the  most  common  of  the  malignant  type. 

Gangrene. — Gangrene,  usually  of  the  moist  type,  occurs  some- 
times in  individuals  whose  vitality  is  at  a  low  ebb,  by  reason  of 
some  exhaustive  infectious  fever,  e.g.,  typhoid  and  malaria;  and  in 
the  debilitated.  It  may  also  arise  as  a  result  of  injury  or  of  inflam- 
mation. The  gangrenous  process  is  in  most  instances  confined  to 
the  prepuce  and  glans,  but  may  be  quite  extensive. 

Treatment  consists  in  keeping  the  parts  dry  and  clean  as 
possible.  Perineal  drainage  is  indicated  when  the  urethra  is  in- 
volved. This,  incidentally,  prevents  the  dressings,  etc.,  becoming 
spiled  by  the  urine,  which  would  otherwise  occur.  The  penis 
should  be  ele^-ated  and  hot  fomentations  continually  applied. 

Elephantiasis  of  the  penis  is  rarely  seen  in  this  country.  It  is, 
however,  very  frequently  met  with  in  the  tropical  and  sub-tropical 
countries. 

The  organ  assumes  enormous  proportions  and  is  due  to  hyper- 
trophy of  the  cellular  tissues. 

Lymphangitis  occurs  commonly  as  a  result  of  chancre,  chan- 
croid, or  mixed  infection  or  in  gonorrhoea.  The  condition  may  be 
simply  temporary  or  persist  for  a  long  period  of  time. 

Phlebitis  often  resembles  lymphangitis  and  frequently  accom- 


PRIAPISM.  79 

panies  it.  The  veins  involved  are  nearly  always  superficial. 
Commonly,  it  is  limited  to  one  vein. 

Cavernitis  or  penitis,  as  it  is  sometimes  called,  is  an  inflamma- 
tion of  the  corpora  cavernosa,  usually  due  to  folliculitis  or  extrava- 
sation of  urine.  The  condition  may  be  extensive,  resulting  in 
sloughing  of- the  erectile  tissues.  The  symptoms  in  the  beginning 
are  oedema  of  the  prepuce,  induration  of  the  corpora  cavernosa, 
and  priapism  which  is  painless. 

Treatment. — Free  incisions  into  the  capsule  immediately.  The 
erectile  powers  of  the  affected  side  are  always  more  or  less  im- 
paired. 

The  benign  new  growths  of  which  the  penis  may  be  the  seat 
are  sebaceous  tumors,  naevi,  varicose  conditions,  and  fatty  tumors. 

Fracture  of  the  penis  is  rare;  the  most  common  cause  is  forced 
coitus,  though  it  may  occur  from  trauma  during  chordee. 

Sjmiptoms  are  those  of  extravasation  of  blood.  Gangrene  and 
pyemia  and  extravasation  of  urine  may  result. 

Curvature. — This  anomalous  condition  is  seen  sometimes  where 
there  is  contraction  or  shortening  of  the  frasnum,  or  from  adhesion 
with  the  scrotum  in  case  of  hypospadias. 

Treatment  depends  upon  the  cause.  Relief  is  usually  obtained 
by  surgical  intervention. 


CHAPTER  IV. 

SURGICAL  AFFECTIONS  OF  THE  URETHRA. 

The  Anatomy  and  Physiology  of  the  Urethra. 

The  urethra  is  a  musculo-membranous  tube  extending  from  the 
meatus  urinarius  to  the  bladder,  which  for  dinical  considerations 
may  be  divided  into  two  parts:  (i)  the  anterior  urethra  or  pars  anterior 
and  (2)  the  posterior  urethra  or  pars  posterior.  The  dividing  Hne 
of  these  anatomical  divisions  is  the  anterior  leaflet  of  the  triangular 

LIGAMENT. 

The  urethra  by  some  authorities  is  divided  into  three  portions. 
The  penile,  membranous,  and  prostatic  urethra.  In  the  adult 
male  the  penile,  spongy,  or  pendulous  urethra  is  about  six  inches  in 
length  and  extends  from  the  meatus  urinarius  to  the  opening  in  the 
triangular  ligament,  where  it  joins  the  membranous  portion.  This 
constitutes  the  anterior  urethra.  The  two  latter  divisions,  mem- 
branous and  prostatic,  constituted  the  deep,  fixed,  or  posterior 
urethra.  The  membranous  portion  is  about  3  /  4  of  an  inch  in  length 
and  extends  from  the  anterior  to  the  posterior  leaflet  of  the  tri- 
angular ligament.  The  prostatic  urethra  averages  i  inch  in  length, 
and  lies  between  the  intravesicular  and  membranous  portions. 
(Figs.  19  and  20.) 

The  total  length  of  the  urethra  varies  in  different  individuals, 
but  averages  approximately  from  eight  to  nine  inches.  The  function 
of  this  canal  is  intimately  concerned  in  both  urination  and  the  re- 
productive processes.  While  in  the  pendulous  urethra  the  curve 
may  be  adapted  at  will,  it  is  the  reverse  in  the  posterior  portion, 
which  is  practically  a  fixed  tube;  therefore  this  fact  must  be  remem- 
bered during  the  passage  of  steel  instruments. 

80 


PENILE,    MEMBRANOUS    ANE    PROSTATIC    URETHRA.  8l 


Pliea  uretica 


SECTION  OF  BLADDER  — 


PROSTATIC  SINUS  WITH  OPENING  OF 
PROSTATIC   GLANDS 

SINUS  POCULARIS 
FOLLICULAR  GLANDS  OF  DORSAL  WALL 


COWPER'S  GLAND 


SEPTUM  PECTINIFORME 


THIN  LAYER  OF  CORPUS  SPONGIOSUM 1 

ORIFICE  OF  COWPER'S  GLAND 


Albuginea  of  corpora  cavernosa 


FOSSA  NAVICULARIS 


SECTION  OF  PROSTATE 

VERUMONTANUM 
EJACULATORY  DUCT 
PROSTATIC  GLANDS 


MEMBRANOUS  URETHRA 


SECTION  OF  CORPUS  CAVERN08UM 


BULBOUS  PORTION  OF  URETHRA 


Mucous  membrane 


PREPUCE 
GLANS  PENIS 


EXTERNAL  URINARY  MEATUS 
Fig.   19. — Male  urethra,  showing  ventral  mucous  wall.      (After  Morris.) 
6 


82 


SURGICAL  AFFECTIONS    OF    THE    URETHRA. 


^      Posterior  Portion 


Anterior  Portion 


Fig.   20. — Diagram  of  the  male  urethra. 

1.  Ureteral  orifice.  9.     Prostatic  sinuses. 

2.  Trigonum  vesicae.  10.     Triangular  ligament. 

3.  Vesical  outlet.  11.     Cowper's  glands. 

4.  1  B.  M.  J.   Bulbo-membranous  junctien. 
r  Prostate  gland.  t 

5.  J                  ^  12.     Lacunae  magna. 

6.  Verumontanum.  13.     Crypts  Morgagni. 

7.  Sinus  pocularis.  14.     Glands  Littre. 

8.  Ejaculatory  ducts  15.     Meatus  urinarius. 


PROSTATIC    URETHRA.  83 

The  meatus  iirinarius  is  the  narrowest  portion  of  the  canal  and 
its  function  is  to  direct  the  outflow  of  semen  and  urine.  It  varies 
considerably  in  size,  but  normally  is  about  twenty-eight  millimeters 
in  its  diameter,  but  is  sometimes  narrowed  by  the  thick  floor  of  the 
FOSSA  NAVicuLARis,  in  which  instance,  when  it  is  associated  with 
urethral  disease  or  reflex  disturbances,  it  becomes  necessary  to 
perform  a  meatotomy. 

Oftentimes  the  narrowed  condition  of  the  meatus  is  due  to  a  thin 
membranous  fold  or  congenital  band  at  its  lower  commissure,  which 
is  dilatable,  and  therefore  is  of  no  surgical  importance.  (The 
entire  female  urethra  averages  about  two  inches  in  length.) 

The  corpis  spongiosum  forms  a  vestment  for  the  penile  or  pen- 
dulous URETHRA,  hence  it  is  sometimes  referred  to  as  the  spongy 
urethra.  Imbedded  in  the  mucous  membrane  of  this  section  is  a 
large  iiumber  of  mucoid  glands  known  as  the  glands  of  Littre, 
which  communicate  with  the  urethra,  through  the  sinuses  or 
CRYPTS  OF  Morgagni.  These  follicles  play  a  very  important  role 
in  the  various  urethral  affections. 

The  MEMBRANOUS  Urethra  is  surrounded  by  the  compressor 
urethrce  and  accelerator  urince  muscles.  The  function  of  these 
muscles  is  exceedingly  important  and  according  to  Lydston,  the 
membranous  portion  constitutes  the  true  sphincter  of  the  bladder, 
which  is  under  volitional  control,  while  the  sympathetic  nerve  fibres 
supplied  to  the  muscle  preserves  its  tonicity. 

The  steady  pressure  of  the  detrusor  urincB  muscle  is  enabled  to 
overcome  the  slight  remaining  resistance  of  the  true  vesical  sphincter, 
with  resulting  voluntary  micturition.  Direct  or  reflex  excitation  of 
this  portion  of  the  canal  is  likely  to  result  in  retention  of  urine. 
Paralysis  of  the  membranous  urethra  on  the  other  hand  producing 
urinary  incontinence. 

On  the  floor  of  the  prostatic  urethra  there  is  a  slight  elevation 
of  the  mucous  membrane  which  is  called  the  verumontamim.  The 
supposed  function  of  this  structure  is  to  prevent  the  regurgitation  of 
the  seminal  secretion.  Here  the  ejaculatory  ducts,  which  are  the 
outlets  of  the  seminal  vesicles,  communicate  with  the  urethra  and 


84  SURGICAL  AFFECTIONS    OF    THE    URETHRA. 

also  the  sinus  pocularis,  through  which  prostatic  fluid  makes  its  exit. 

The  intravesicular  urethra  is  trianglar  in  shape  and  is  bounded 
at  each  posterior  angle  by  the  ureteral  orifices.  The  anterior  in- 
ferior angle  is  bounded  by  the  prostatic  urethra.  Extending  be- 
tween the  ureteral  openings  is  a  fold  of  mucous  membrane  forming 
a  curve,  caused  by  a  projection  of  muscular  fibres  called  the  plica 
ureterica.  The  color  of  the  mucous  membrane  of  the  intravesicular 
urethra  is  darker  than  that  of  the  bladder  and  is  covered  with 
stratified  squamous  epithelium. 

The  triangular  ligament  or  deep  perineal  fascia,  as  it  is  sometimes 
called,  is  divided  into  two  layers  or  folds,  anterior  and  posterior,  in 
which  lies  the  membranous  urethra.  Between  these  folds  are  also 
the  Cowper's  glands,  which  empty  their  secretion  into  the  urethra, 
through  a  duct  opening  in  the  bulb  directly  in  front  of  the  anterior 
layer  of  the  triangular  ligament.  Therefore,  when  the  glands  be- 
come involved,  the  infecting  process  is  merely  an  extension  from  the 
anterior  urethra,  and  thus  is  a  complication  of  anterior  urethritis. 

Another  very  important  structure  closely  allied  to  the  urethra  is 
Buck^s  fascia,  or  the  deep  layer  of  the  superficial  perineal  fascia. 
It  is  attached  laterally  to  the  rami  of  the  pubes  and  ischia,  and  poste- 
riorly to  the  triangular  ligament,  thus  preventing  extravasations  of 
fluids  into  the  perineum.  By  reason  of  its  continuation  with  the 
abdominal  fascia,  above,  it  prevents  extravasations  into  the  ab- 
domen. In  its  downward  course  Buck's  fascia  divides  into  two 
layers,  forming  a  vestment  for  the  corpora  cavernosa  and  spon- 
giosum and  then  in  resemblance  to  an  apron,  dips  downward  into 
the  perineum.  The  anatomy  of  the  triangular  ligament  and  Buck's 
fascia  is  extremely  important  in  considering  urinary  extravasations. 

AFFECTIONS  OF  THE  URETHRA. 

Urethral  Calculi. — One  or  more  calculi  may  be  lodged  in  any 
portion  of  the  urethra.  They  originate  in  the  kidney  or  bladder 
but  become  impacted  in  the  narrow  tract  and  here  may  attain  con- 
siderable proportions,  so  as  to  impede  the  outward  flow  of  the  urine. 


STRICTURE    OF    THE    MALE    URETHRA.  85 

Diagnosis. — The  presence  of  the  urethral  calculi  is  readily  de- 
tected by  palpation  along  the  floor  of  the  urethra,  or  by  the  use  of  the 
endoscope.  The  passage  of  a  bougie  will  impart  a  grating  sensation 
to  the  fingers,  and  may  more  or  less  obstruct  the  passage  of  the 
instrument. 

Treatment.— They  may  be  removed  under  local  anaesthesia, 
by  means  of  an  alligator  forceps.  If  this  fails  a  small  incision  must 
be  made  at  the  seat  of  the  lodgment,  and  the  stone  removed  through 
the  wound.  A  soft  rubber  catheter  is  now  introduced  into  the 
urethra  via  the  meatus  and  around  it  the  opening  is  sutured. 

FOREIGN  BODIES. 

The  entrance  of  foreign  bodies  into  the  urethra  is  often  effected  for 
the  purpose  of  sexual  gratification,  or  by  the  accidental  breaking  of 
some  urethral  instrument,  e.g.,  filiform  bougies,  etc.  The  symptoms 
and  treatment  are  practically  the  same  as  those  of  urethral  calculi. 

STRICTURE  OF  THE  MALE  URETHRA. 

By  the  term  stricture  is  implied  a  stenosis  or  diminution  of  the 
calibre  of  a  portion  of  the  urethra.  The  lumen  is  narrowed  as  a 
result  of  contraction  in  some  localized  chronic  inflammatory  process, 
giving  rise  to  permanent  cell  changes  with  small  cell  infiltration  into 
the  submucous  layers  of  the  urethra  and  chronic  catarrhal  inflamma- 
tion of  the  overlying  mucous  membrane.  The  dilatability  of  the 
tissues  is  thus  impaired,  interfering  more  or  less  with  the  function  of 
the  tract.  This  condition  is  in  90  per  cent,  of  the  cases  the  sequel  of 
gonorrhoeal  infection,  but  may  also  result  from  traumations,  e.g., 
from  unskillful  use  of  urethral  instruments,  etc. 

There  are  two  distinct  types  of  stricture,  namely,  the  congenital 
and  the  acquired.  The  congenital  variety  is  comparatively  rare. 
The  calibre  of  the  normal  urethra  averages  from  27  to  30  French. 
Every  urethra  presents  its  own  calibre  and  dilatability,  hence  it  is 
difficult  to  lay  down  any  specific  dimensions  of  just  what  constitutes 
the  normal  calibre.  The  widest  portions  of  the  urethra  vary  from 
30  to  40  F.     The  latter  dimension  represents  the  middle  of  the 


86        SURGICAL  AFFECTIONS  OF  THE  URETHRA. 

prostatic  urethra.  The  common  seat  of  stricture  is  at  the  junction 
of  the  membranous  and  bulbous  urethrce.  Strictures  occurring  in  the 
pendulous  urethra  are  nearly  always  gonorrhceal,  and  are  usually 
resilient.  The  terms  hard,  semi-fibrous,  and  soft  strictures  are 
descriptive  of  their  density  according  to  the  extent  of  fibrous  pro- 
liferation. 

These  connective-tissue  changes  are  as  a  rule  limited  to  the  sub- 
mucous layers  only,  but  may  later  involve  the  muscular  layer  also. 
The  morbid  process,  instead  of  remaining  localized  at  the  bulbo- 
membranous  junction,  may  extend  over  the  entire  membranous 
urethra,  but  this  fortunately  is  rare.  Gonorrhoeal  stricture  never 
occurs  in  the  prostatic  portion. 

Causes. — Gonorrhoea  is  the  chief  cause  of  acquired  stricture. 
Trauma  is  the  next  most  frequent  cause.  Rare  cases  have  been 
chronicled  in  which  the  stenosis  has  been  ascribed  to  the  healing  of 
chancre  and  chancroid,  also  scleroderma  and  keloid  of  the  glans 
penis. 

STRICTURE  OF  THE  FEMALE  URETHRA. 

This  affection  is  comparatively  rare.  It  -may  be  found  in  lith- 
aemic  subjects  and  in  masturbators  also,  as  a  result  of  laceration  by 
the  introduction  of  foreign  bodies,  used  for  the  purpose  of  sexual 
gratification.  It  may  also  be  caused  by  traumatism  and  chancres. 
The  symptoms  are  chiefly  those  of  an  irritable  bladder.  Some  cases 
present  a  nodular  condition  of  the  urethra  felt  distinctly  by 
pressure  of  the  finger  along  the  floor  of  the  canal.  The  passage  of 
urine  may  be  interfered  with  or  completely  obstructed.  Retention 
is  usually  caused  by  exposure  to  cold,  sudden  changes  of  tempera- 
ture, alcoholic  or  sexual  excesses. 

Treatment. — The  urethra  being  rendered  surgically  clean,  an 
incision  is  made  on  the  upper  and  lower  wall  of  the  urethra,  employ- 
ing for  this  purpose  a  straight  blunt  tenotome  or  bistoury  or  a 
Gouley's  beaked  bistoury.  This  should  be  followed  by  hot  boric 
or  diluted  silver  irrigations.  The  latter  is  especially  indicated  if 
the  bladder  is  infected. 


TRAUMATIC    STRICTURE.  87 

CONGESTIVE   OR  INFLAMMATORY  STRICTURE. 

The  so-called  congestive  or  inflammatory  stricture  is  really  a 
complication  of  a  pre-existing  organic  stricture  which  in  consequence 
of  a  debauch  or  sexual  excesses,  cold,  horseback  riding,  violent 
exercising,  etc.,  becomes  congested  and  inflamed  at  the  narrowed 
portion  of  the  canal.  It  is  usually  of  short  duration,  however,  and 
its  treatment  is  the  same  as  for  spasmodic  condition. 

TRAUMATIC  STRICTURE. 

As  its  name  implies,  is  caused  by  injuries,  e.g.,  falls  or  kick  in  the 
perineum.  The  seat  of  such  strictures  is  generally  at  the  triangular 
ligament,  and  but  very  rarely  in  the  pendulous  urethra.  The  nar- 
rowing is  due  to  cicatricial  contraction  and  will  not  yield  to  gradual 
dilatation.  It  becomes  necessary,  therefore,  in  most  cases  to  do  a 
perineal  section. 

CLASSIFICATION  OF  STRICTURE  OF  THE  MALE 

URETHRA. 


1.  Spasmodic, 

^  f  (a)  Congenital 

2.  Organic.      <  '  ,   .      ^.     , 

I  (0)  Acquired. 


ACQUIRED  STRICTURE. 


CLINICAL 
FEATURES. 

CHARACTER 
OR   DENSITY. 

VARIETY. 

SIZE. 

CAUSES. 

Simple,    uncompli- 

Soft. 

Linear. 

Calibre. 

Travunatism 

cated    or    dilata- 

Semifibrous. 

Above 

ble. 

Fibrous  or  inodular. 

Annular. 

15  F. 

Mechanical 

Spasmodic. 

large. 

or  Pressure 

Irritable. 

Cicatricial   or   nodu- 

j 

Inflamed. 

lar. 

Below 

Congenital. 

Resilient  or  elastic. 

Tortuous. 

15  F. 

Recurrent. 

- 

small. 

Gonorrhoeal 

88  SURGICAL   AFFECTIONS    OF    THE    URETHRA. 

Congenital  Stricture. — This  malformation,  due  to  defective 
foetal  development,  is  much  commoner  than  one  would  be  led  to 
suppose  from  the  very  scanty  literature  on  the  subject.  The  chief 
points  to  be  borne  in  mind  are:  (i)  That  the  urethra  is  formed  by 
three  embryologic  portions:  (a)  the  posterior  urethra  developed 
from  the  urogenital  sinus,  and  separated  from  the  next  portion  by 
the  cloacal  membrane;  (b)  the  spongy  portion  developed  from  the 
urethral  groove  and  closed  during  the  first  stage  of  its  development 
by  the  cloacal  membrane,  at  its  posterior  extremity,  and  the  epi- 
thelial wall  of  glans,  at  its  anterior;  (c)  the  balanic  portion  devel- 
oped independently.  (2)  The  spongy  and  the  balanic  portions; 
i.e.,  the  whole  anterior  urethra,  are  not  derived  as  the  posterior, 
from  a  hollow  embryonic  organ,  but,  on  the  contrary,  developed 
in  a  solid,  continuous  mass  of  epithelial  cells.  It  is  therefore  not 
surprising  that  congenital  strictures  are  more  common  in  the  ante- 
rior than  in  the  posterior  urethra.  The  contraction  is  usually  at 
the  meatus  or  distal  end  of  the  fossa  navicularis  due  to  a  partial 
occlusion  by  a  thin  membranous  septum  or  band  at  the  lower  com- 
missure of  the  opening.  Nocturnal  incontinence  and  diurnal  fre- 
quency of  micturition  are  characteristic  features.  Incontinence  in 
children,  if  not  accounted  for  by  some  evident  external  malforma- 
tion, is  frequently  due  to  a  congenital  stricture  and  not  to  ''essential 
incontinence,"  or  to  "congenital  irritability,"  as  it  is  usually  alleged 
In  adults  every  stricture  is  not  necessarily  the  result  of  trauma  or 
gonorrhoea,  and  gonorrhceal  strictures  develop  much  more  quickly 
on  the  basis  of  an  already  existing  congenital  stenosis.  The  treat- 
ment is  gradual  dilation;  only  rarely  is  it  necessary  to  resort  to  in- 
ternal or  external  urethrotomy. 

SPASMODIC  STRICTURE. 

Urethrismus,  as  it  is  sometimes  called,  or  spasmodic  contrac- 
tion of  the  urethra  may  occur  in  patients  of  a  high  nervous  tem- 
perament in  whom  even  the  passage  of  an  instrument  excites^ 
spasm  of  the  urethral  walls  as  a  result  of  a  reflex  contraction- of 


SPASMODIC    STRICTURE.  89 

the  muscular  fibres  firmly  grasping  the  instrument  as  it  is  with- 
drawn. The  stenosis  may  occur  in  any  portion  of  the  canal  due 
to  contraction  of  the  circular  fibres  of  the  muscular  layer  but  in 
most  instances  the  cut-off  muscle  is  the  factor  chiefly  responsible 
for  spasmodic  contraction.  Therefore  the  principal  seat  of  this 
form  of  stricture  is  in  the  membranous  urethra. 

The  CAUSES  may  be  predisposing  or  exciting.  The  predisposing 
factors  are  (a)  hyperaesthesia,  (b)  acute  and  chronic  diseases  of  the 
urinary  organs,  i.e.,  granular  and  congested  patches,  (c)  abrasions 
or  lacerations  occasioned  by  an  instrument,  (d)  hyperacidity  of  the 
urine — irritation,  (e)  irritation  about  the  rectum  from  the  presence 
of  tapeworm,  hemorrhoids,  fissure  of  the  anus,  fecal  accumulation, 
operation  upon  the  rectum,  testes,  or  cord,  passage  of  instruments, 
sexual  excitement,  or  reflex  irritation. 

Exciting  Causes. — Stone  in  the  bladder  or  urethra,  organic 
stricture  of  the  urethra,  a  full  bladder,  sudden  temperature 
changes,  fright  and  gastro-intestinal  disturbances,  drugs,  e.g., 
cantharides  and  turpentine. 

Diagnosis. — In  determining  whether  the  inability  to  voluntarily 
empty  the  bladder  is  spasmodic  or  not,  it  is,  in  the  majority  of 
cases,  comparatively  simple.  The  history  of  its  sudden  onset,  a 
survey  of  his  general  condition,  and  an  examination  of  the  urethra 
and  prostate  wall  will  usually  furnish  sufficient  data  to  establish 
the  nature  of  the  obstruction. 

Treatment. — The  source  of  the  irritation,  whether  local  or  re- 
flex, must  be  ascertained  and  then  removed.  The  urine  must  be 
kept  non-irritating  by  the  administration  of  alkaline  waters  and 
the  avoidance  of  stimulating  or  charged  drinks,  highly  seasoned 
foods.  Antispasmodics  or  sedatives  should  be  given  and  further 
instrumentation  of  the  urethra  stopped.  The  hot  sitz  bath  and  a 
1/4  gr.  morphia  hypodermatically  and  ten  grs.  quinine  are  usually 
suflficient  to  relax  the  spasm.  These  measures  may  be  still  further 
supplemented  if  necessary  by  a  hot  application  over  the  pubes  and 
a  hot  lemonade  to  produce  active  diaphoresis.  Should  these  efforts 
fail,  a  small  size  soft  rubber  catheter  may  be  introduced  while  the 


90 


SURGICAL   AFFECTIONS    OF    THE    URETHRA. 


patient  is  still  in  the  bath.     For  further  treatment  of  this  condition 
see  chapter  on  retention  of  urine.  ^ 

ORGANIC  STRICTURE. 

This  is  the  form  of  stricture  which  is  due  to  a  deposit  of  con- 
nective tissue,  with  fibrous  contraction.  It  may  be  congenital  or 
acquired.     It  is  most  commonly  the  result  of  urethritis. 

PATHOLOGY  OF  STRICTURE. 

Assuming  that  the  narrowing  within  some  portion  of  the  urethra 
is  due  to  urethritis,  usually  chronic,  there  first  Qccurs  an  infiltra- 
tion of  newly  formed  submucous  tissue,  which  diminishes  the  call- 


>< 


X 


Fig. 


a  h  f 

-(a)   Linear,      (b)   Annular,     (c)   Tortuous.      (After  Casper.) 


bre  of  the  canal  and  from  the  character  of  its  density  is  called 
"soft  stricture."  Eventually  this  tissue  becomes  more  inelastic  as 
a  result  of  further  submucous  connective-tissue  proliferation,  which 
condition  is  called  semi-fibrous  stricture.  They  are  both  "succu- 
lent'' until  condensation  still  further  ensues  when  the  terms  nodu- 
lar, fibrous,  or  hard  strictures  are  applied  to  it. 


VARIETIES    OF    ORGANIC    STRICTURE.  QE 

The  new  connective  tissue  formation,  whether  it  be  linear,  an- 
nular, or  tortuous,  may  lie  very  superficially  without  invading  the 
wall  of  the  urethra  at  all.  In  other  cases  the  diminution  in  the 
calibre  of  the  canal  might  be  so  marked  involving  extensively  into 
the  urethral  wall  almost  down  to  the  cofpus  spongiosum.  The 
overlying  mucous  membrane  is  considerably  thickened  and  vas- 
cular. The  fibrous  contraction  causes  the  narrowing  of  the  lumen 
with  a  proportionate  degree  of  inelasticity. 

VARIETIES  OF  ORGANIC  STRICTURE. 

The  character  of  the  narrowing  presents  three  principal  varieties, 
viz. :  linear,  annular,  and  tortuous. 

These  have  been  again  divided  according  to  their  clinical  features 
as  follows: 

(a)  Simple  (dilatable). 

(b)  Irritable  (involving  a  condition  of  hyperemia  and  hyperaesthesia) . 

(c)  Resilient  or  elastic. 

(d)  Recurrent. 

LOCATION  OF  ORGANIC  STRICTURE. 

The  most  common  location  by  far  is  at  or  near  the  bulho-mem- 
branous  junction  (sometimes  designated  B.  M.  J.),  although  this 
has  been  the  subject  of  much  discussion.  The  next  most  frequent 
points  are  at  the  meatus  or  just  within  it  and  the  junction  of  the 
bulb  and  fossa  navicularis  or  just  posterior  to  it,  i.e.,  two  to  three 
inches  from  the  meatus;  and  least  seldom  about  one  inch  anterior 
to  the  bulbo-membranous  junction.  Stricture  never  involves  the 
prostatic  urethra. 

SYMPTOMS  OF  STRICTURE. 

Almost  the  first  symptom,  or  early  in  the  formation  of  a  stricture, 
there  will  be  noticed  a  persistent  discharge,  muco-purulent  in  char- 
acter, particularly  in  the  morning  on  arising.     Examination  of  the 


92  SURGICAL  AFFECTIONS    OF    THE    URETHRA. 

urine  by  the  two  glass  test  will  find  its  substance  perfectly  clear 
and  containing  a  few  threads  and  epithelium. 

The  SUBJECTIVE  SYMPTOMS  present  in  this  condition  are  a 
sense  of  burning  during  micturition.  There  may  or  may  not  be 
increased  frequency  of  urination  with  slight  pain  at  its  termination 
as  in  some  cases  which  may  be  associated  with  a  urethro  cystitis 
or  cystitis  as  often  occurs  in  old  cases.  Sooner  or  later  the  patient 
notices  that  additional  effort  is  required  in  the  act  of  urination  as 
a  consequence  of  impaired  expulsive  force.  The  severity  of  this 
symptom  is  usually  proportionate  to  the  degree  of  contraction. 
In  most  cases  the  process  of  its  formation  is  so*  insidious  that  this 
symptom  may  not  be  noticed,  owing  to  the  bladder  gradually  con- 
forming itself  by  a  compensating  hypertrophy  of  the  muscular 
fibres.  Alteration  of  the  urinary  stream  is  another  significant 
symptom.  The  changes  noticed  depend  largely  upon  the  contour 
of  the  narrowing.  The  character  of  the  stream  may  be  thin  and 
twisted,  double  or  forked,  thick  and  broad,  ''fan-like"  (Taylor).  It 
may  project  strongly,  with  some  hesitancy  in  starting  and  interrup- 
tion during  its  passage.  In  other  instances  the  parabolic  curve  is 
markedly  diminished.  Dribbling  of  urine  after  micturition  almost 
invariably  occurs  in  well  advanced  cases.  This  is  obvious,  owing 
to  the  diminished  elasticity  of  the  urethral  walls  with  imperfect 
closure  of  the  canals  and  a  consequent  inability  of  the  accelerator 
urinae  muscle  to  functionate  completely.  The  hesitancy  or  diffi- 
culty in  starting  the  stream  becomes  more  marked  as  the  stenosis 
or  impediment  increases.  To  overcome  this  the  patient  exerts 
himself  more  or  less  which  is  attended  with  pain  and  a  constant 
desire  to  urinate,  and  when  the  act  is  begun,  soon  interrupted.  The 
pain  may  be  constant  and  dull  or  spasmodic  in  the  glans  penis 
simulating  vesical  calculi.  The  region  of  discomfort  is  suprapubic 
as  a  rule,  but  may  radiate  on  to  the  perineum,  pubes,  testes,  vas 
deferentia,  and  groins. 

Hypertrophy  of  the  bladder  walls  (muscular  layers  and  con- 
nective tissue)  is  another  serious  sequel  which  sooner  or  later 
develops  in  the  course  of  stricture.     The  membrane  assumes  a 


SYMPTOMS    OF    STRICTURE. 


93 


villous  appearance,  presenting  deep  and  thickened  ridges.  In  some 
cases  the  reverse  is  true  and  as  a  consequence  increased  pressure 
exerted  on  the  thinned  walls.  Rupture  may  occur  with  extravasa- 
tion of  its  contents  into  the  peritoneal  cavity  or  pelvic  connective 
tissue  behind  the  posterior  layer  of  the  trian- 
gular ligament  (see  chapter  on  rupture  of  the 
bladder). 

The  MORBID  CHANGES  IN  THE  URINE  are  highly 
significant  when  accompanying  any  stricture. 
From  an  acid  reaction  and  slightly  cloudy,  it 
becomes  opaque  and  ammoniacal  and  fetid,  as 
a  result  of  decomposition  in  the  bladder.  Not 
infrequently  there  may  be  emissions,  organic  im- 
potence, pain  on  coitus  with  stabbing  sensation 
accompanying  the  ejaculation.  In  not  a  few  in- 
stances the  irritation  of  stricture  produces  ob- 
stinate priapism  and  excessive  desire,    . 

Complications  of  Stricture. — Besides  super- 
ficial and  deep  ulcerations,  false  passages,  infiltra- 
tion and  retention  of  urine,  rupture  of  the  bladder, 
and  pouch  formation  behind  the  seat  of  the  stric- 
ture, there  may  develop  abscesses  and  fistulas. 
The  abscess  generally  begins  in  inflamed  follicles 
and  burrows  in  any  direction  resulting  in  a  fistu- 
lous opening  in  the  perineum  or  scrotum.  In  old 
and  advanced  cases  of  stricture,  where  the  condi- 
tion has  been  subjected  to  much  instrumentation, 
there  may  develop  abscessea  of  the  prostate  which 
sometimes  discharge  into  the  rectum,  urethra,  or 
perineum. 

The  ureters  themselves  or  together  with  the 
pelves — calices  and  infundibula  may  become  more  or  less  distended 
and  thus  become  the  seat  of  chronic  inflammation.  The  patient 
under  these  circumstances  soon  declines  in  his  general  health.  His 
appetite  is  poor,  he  loses  weight  and  complains  of  pain  in  the  back 


:3o 


^JiHTz\\ 


Fig.   22. — Conical 
steel  bougie. 


94  SURGICAL  AFFECTIONS    OF    THE    URETHR.A. 

and  loins.  There  is  a  constant  desire  to  empty  the  bladder  and 
when  an  attempt  is  made  to  accomplish  the  act  it  is  attended  with 
hesitancy  and  straining  and  ardor  urinae.  Should  he 
succeed  in  passing  a  few  drops  it  will  be  found  ammo- 
niacal.  The  agony  increases  unless  relief  is  given  and 
the  patient  passes  into  a  state  of  collapse,  with  subse- 
quent urethral  fever,  or  death  will  ensue  from  exhaustion. 
Exploration  of  the  Urethra. — The  diagnosis  of 
organic  stricture  cannot  be  made  without  instrumental 
examination.  Therefore  any  abnormal  narrowing  of  the 
meatus  must  be  enlarged  to  the  normal  calibre,  i.e.,  28 
French  (approximate)  (meatotomy)  so  as  to  permit  the 
introduction  of  the  necessary  instruments  incidental  to 
a  thorough  investigation  of  the  canal.  The  instrument 
most  largely  employed  in  the  diagnosis  of  stricture  is 
the  bougie,  which  may  be  flexible  or  of  solid  metal. 
These  are  graduated  in  size,  according  to  the  French 
scale,  each  unit  of  which  represents  one  third  of  a  milli- 
meter. In  other  words  an  18  F.  bougie  would  be  equiv- 
alent to  6  m.,  a  24  F.  to  8  m.,  etc.  The  English  scale 
ranges  from  6  to  18. 

Sounds. — The  conical  steel  bougie,  as  it  is  often  called, 
is  said  to  be  most  useful  when  it  has  a  short  curve  and 
a  conical  end.  The  entire  instrument  should  be  per- 
fectly smooth  and  the  point  rounded  but  several  sizes 
smaller  than  the  shaft,  giving  it  a  conical  form.  The 
Van  Buren  sound  fulfills  these  requirements  and  is 
largely  employed.  (Fig.  22.)  A  slight  modification  of 
the  straight  conical  sound  is  found  in  the  Beneque's 
bougie.  This  has  a  long  double  curve  beginning 
^T^?"  •l^/'~      almost  at  the  middle  of  the  shaft.     The  curve  is  thus 

Flexible 

olivary         designed  to  conform  to  the  two  curves  of  the  urethra, 
bougie.        rj.-^^  ^gg  q£  straight  steel  sounds  is  sometimes  indicated, 
and  particularly  of  value  in  strictures  in  the  pendulous  urethra. 
Olivary  or  Flexible  Bougie?. — These  are  principally  of  rubber 


SOUNDS. 


95 


which  may  contain  shot  so  as  to  better  enable  its  passage  by  gravity. 
(Fig.  23.)  In  order  for  this  instrument  to  be  of  service  it  should  be 
perfectly  smooth  along  its  entire  length.  It  should  be  sufficiently 
flexible  to  adapt  itself  readily  to  the  course  of  the  canal, 
but  at  the  same  time  must  not  be  over  supple. 

The  olivary  tip  and  neck  should  taper  so  as  to  be 
several  sizes  smaller  than  the  shaft.  A  complete  set  of 
these  instruments  is  a  most  necessary  adjunct  to  a  genito- 
urinary equipment.  The  most  useful  sizes  range  from 
Nos.  8  to  24  F.  When  the  case  calls  for  an  instrument 
beyond  this  measurement  the  steel  bougie  is  preferable. 
The  care  of  flexible  instruments  is  important  as  they  are 
expensive.  They  should  be  kept  in  a  glass  tube  which 
must  be  perfectly  dry  and  air-tight  and  kept  in  a  cool  place. 
If  they  tend  to  become  gummy,  powdered  French  chalk 
sprinkled  over  the  surface  will  prevent  their  sticking 
together. 

Whalebone  filiform  guides  are  particularly  of  service 
in  cases  of  very  tight  stricture  in  which  the  lumen  is  so  nar- 
row and  tortuous  as  to  prevent  the  passage  of  even  the 
smallest  bulbous  or  conical  bougie.  When  we  have  re- 
course to  the  filiform  guide  it  may  be  necessary  in  order  to 
find  the  opening  to  pass  a  number,  say  six  or  eight,  of 
these  guides  upon  the  point  of  coarction  and  manipulating 
successively  one  at  a  time,  to  enter  the  opening.  Some- 
times their  introduction  is  facilitated  by  bending  the  whale- 
bone about  1/2  inch  from  its  tip.  It  is  always  well  to  in- 
ject 5ii  oi  olive  oil  or  iodoform  emulsion  into  the  urethra. 
This  serves  a  twofold  purpose;  first,  by  lubricating  the  fig.  24.— 
canal  and  secondly  by  distendino-  the  contracted  portion   Bougie  a 

r     .  ,  boule. 

of  the  urethra. 

If  after  numerous  attempts  great  difficulty  is  encountered  in  intro- 
ducing the  instrument  it  is  safer  not  to  withdraw  it  but  to  leave  it 
remain,  tying  it  in  place;  this  will  have  the  effect  of  continuous 


96 


SURGICAL   AFFECTIONS    OF    THE    URETHRA. 


dilatation  and  will  often  save  considerable  trouble  in  getting  through 
the  stricture  again. 

Bougie  a  Boule. — This  instrument  consists  of  an 
acorn-shaped  tip  or  head,  attached  to  a  flexible  or 
metal  staff.  (Fig.  24.)  The  sizes  range  from  10  to 
30  F.  They  are  extremely  useful  in  detecting  early 
morbid  changes,  i.e.,  thickening  of  the  mucous  mem- 
brane at  any  point  along  the  anterior  urethra. 

Urethrometer  (Otis's)  is  useful  in  cases  in  which 
the  meatus  is  abnormally  small  so  as  to  prevent  the 
introduction  of  instruments  to  explore  the  urethra. 
(Fig.  25.)  It  is  especially  of  service  in  detecting  points 
of  narrowing,  measuring  the  calibre,  and  determining 
the  dilatability  of  the  urethra.  Untoward  effects 
OF  DILATATION  are  urethral  fever,  hemorrhage,  false 
passages,  acute  inflammaion  of  the  prostate,  urethra, 
bladder,  and  epididymis. 

EXAMINATION  OF  STRICTURES. 

The  principal  points  to  be  observed  in  the  prelimi- 
nary consideration  of  a  case  of  stricture  are  to  first 
ascertain  the  date  of  gonorrhoea!  infection,  the  age  at 
which  it  was  acquired,  the  duration,  and  severity,  of 
the  attack.  The  prostate  and  seminal  vesicles  should 
be  carefully  examined.  The  condition  and  function  of 
the  bladder  and  kidneys  must  likewise  be  inquired 
into.  The  urine  should  be  examined  for  threads, 
blood,  pus,  and  casts.  The  general  health  and  habits 
of  the  patient,  his  temperament,  occupation,  also  con- 
stitute a  vital  question  in  the  matter  of  treatment. 
The  next  point  to  determine  is  the  density  of  the  ob- 
structing tissue,  whether  it  be  soft,  succulent  or  semi- 
fibrous,  or  fibroiis.  The  latter  usually  occur  beyond 
the  age  of  35  or  40,  therefore  the  age  of  the  patient 
is  always  a  significant  factor. 


Fig.  25. — 

Otis's 

urethrometer. 


EXAMINATION    OF    STRICTURES. 


97 


Instrumental  Examination. — The  first  instrument  which  it  is 
always  best  to  use  is  an  olivary  bougie  of  about  20  F.  lubricated  with 
lubrichondrin  and  gently  introduced  into  the  urethra  and  continu- 
ing it  downward  until  the  point  of  obstruction  is  encountered.  If 
the  instrument  cannot  be  made  to  enter  farther  than  its  olive  point, 
it  must  be  withdrawn  and  a  small  bougie  a'boule  about  12  F.  care- 
fully inserted.  If  this  succeeds  in  passing  the  stricture  much  in- 
formation as  to  its  density  may  be  obtained  upon  its  withdrawal. 
Some  prefer  the  filiform  guide,  over  which  the  Gouley  tunnelled 
catheter  is  passed.     (Fig.  26.)     In  some  cases  it  may  be  necessary 


Fig.   26. — Gouley's  catheter  staff. 

to  do  a  meatotomy  in  order  to  gain  entrance  to  the  urethra  with 
these  instruments.  This  procedure  is  therefore  justifiable  under 
such  circumstances.  Should  it  be  possible  to  use  a  small  size  conical 
rubber  or  steel  bougie,  much  information  is  often  obtained  by  palpa- 
tion with  the  finger  tips  along  the  floor  of  the  urethra  while  the  in- 
strument is  in  situ.  Areas  of  thickening,  inelasticity,  rings  of  in- 
durated tissue,  may  be  felt  distinctly  as  far  back  as  the  bulb.  In 
exploration  of  the  urethra  there  is  no  occasion  for  causing  the  patient 
any  pain  and  it  must  therefore  be  conducted  carefully  and  with  the 
utmost  gentleness.  Undue  force  is  always  fraught  with  danger  and 
nothing  can  be  accomplished  thereby.  Patience  and  good  judg- 
ment are  at  all  times  essential  in  urethral  examinations.  The  glans 
penis  should  be  cleansed  with  soap  and  water  and  rinsed  with 
bichloride,  care  being  taken  not  to  get  any  into  the  urethra.  If 
there  be  any  urethral  discharge  the  tract  must  be  irrigated.  All 
urethral  instruments  should  be  sterile  and  well  lubricated.  Should 
failure  attend  every  effort  to  pass  through  the  stricture  it  is  deemed 
7 


9^  SURGICAL  AFFECTIONS    OF    THE    URETHILA, 

expedient  to  postpone  further  attempt,  put  the  patient  to  bed,  allow- 
ing him  a  light  diet  and  a  purge  so  as  to  relieve  any  pelvic  conges- 
tion. This  rest  and  relaxation,  with  an  opium  suppository  and  hot 
bath,  followed  by  hot  poultices  or  hot  water  bag  to  the  pubes,  will 
in  most  cases  relieve  any  spasmodic  contraction  or  congestion  of  the 
stricture. 

Technic  of  Introducing  Catheter  or  Sound. — A  catheter  or 
bougie  may  be  comfortably  passed  with  the  patient  either  in  the  stand- 
ing, sitting  or  recumbent  position,  but  the  latter  for  obvious  reasons 
is  always  far  more  preferable.  The  glans  penis  should  be  rendered 
aseptic.  The  operator  standing  at  the  left  of  the  patient  raises  the 
penis  almost  at  a  right  angle  to  the  body  and  retracts  the  foreskin. 
The  instrument,  well  lubricated  and  still  warmed,  is  held  by  the 
thumb  and  forefinger  with  the  shaft  parallel  to  the  abdomen,  the 
handle  directed  outward  and  toward  the  crest  of  the  ilium.  It  is 
then  slowly  passed  in  without  force  by  its  own  weight  as  it  were. 
As  soon  as  the  least  resistance  is  encountered,  which  is  in  most  in- 
stances at  the  penoscrotal  angle,  the  instrument  should  be  slightly 
withdrawn,  directing  the  tip  to  the  upper  surface  of  the  urethra  in 
order  to  escape  the  sinus  of  the  bulb,  and  as  it  glides  beneath  the 
pubes  the  handle  and  shaft  of  the  sound  are  brought  gently  for- 
ward and  down  on  the  median  line  between  the  thighs  when  the 
point  will  usually  enter  the  bladder.  In  some  cases  the  passage  of 
urethral  instruments  is  facilitated  by  putting  tension  on  the  penis 
when  the  tip  is  beyond  the  penoscrotal  angle  so  as  to  stretch  the 
anterior  leaflets  of  the  triangular  ligament.  Difficulty  in  this  pro- 
cedure may  often  be  overcome  by  simply  pressing  against  the  con- 
vexity or  curve  of  the  sound,  by  exerting  gentle  pressure  beyond  the 
scrotum  or  with  the  finger  in  the  rectum  in  order  to  guide  the  tip 
toward  the  symphysis  pubis.  Skill  in  these  manoeuvres  is  soon 
acquired  with  a  little  patience  and  experience.  Any  undue  force  or 
improper  manipulation  will  almost  invariably  excite  spasmodic  con- 
traction of  the  compressor  urethra  muscle  or  of  the  involuntary 
muscular  layers  of  the  pendulous  urethra. 


INSTRUMENTS  FOR  OPERATION  UPON  THE  URETHRA.    99 

TREATMENT  OF  STRICTURE  IN  THE  ANTERIOR 

URETHRA. 

Strictures  in  this  portion  of  the  canal  are  usually  of  the  soft  or 
semifibrous  quality.  The  fibrous  and  inodular  strictures  are  rarely 
found  in  this  situation.  The  density  of  the  contracting  tissue, 
therefore,  is  the  guide  to  the  method  of  treatment.  The  semi- 
fibrous  stricture  is  much  benefited  in  the  early  stages  by  gradual 
dilatation  with  a  straight  conical  steel  bougie  or  by  modified  rapid 
dilatation.  Should  there  be  one  or  more  areas  or  rings  of  fibrous 
infiltration  with  a  calibre  of  less  than  15  F.  scale,  dilatation  is  not 
indicated.     This  condition  calls  for  an  internal  urethrotomy. 

INSTRUMENTS  FOR  OPERATION  UPON  THE  URETHRA. 

The  Maisonneuve  urethrotome  consists  of  a  staff  9  1/2  inches 
in  length  of  calibre  12  F.,  its  upper  surface  grooved  and  slightly  curved 
at  its  distal  end,  which  is  tunnelled  for  1/8  inch.  At  the  end  of  the 
stylet  is  a  triangular  blade  with  a  blunt  apex.  (Fig.  27.)  The  fili- 
form having  passed  down  the  urethra  and  into  the  bladder  if  possible, 
the  grooved  staff  is  inserted  over  the  whalebone  guide  as  far  as  the 
penoscrotal  junction,  and  then  the  stylet  with  the  knife  is  slid 
down  slowly  but  firmly.  In  this  procedure  the  penis  should  be 
held  straight  and  tense.  This  instrument  is  especially  adaptable 
for  strictures  of  small  calibre  in  the  pendulous  urethra.  The 
urethra  may  thus  be  incised  18  to  24  F.  Strictures  seated  near  or 
at  the  meatus  may  be  readily  incised  by  simply  using  a  straight 
blunt  bistoury.     (Fig.  28.) 

The  Maisonneuve  urethrotome  is  a  most  excellent  instrument 
especially  where  the  point  of  coarctation  is  at  or  in  front  of  the  bulbo- 
membranous  junction  or  even  in  the  pendulous  urethra.  It  is 
especially  valuable  in  strictures  at  the  penoscrotal  angle. 

The  TECHNic  of  its  application  is  as  follows:  The  filiform  is 
first  introduced  as  a  guide  and  the  shaft  of  the  instrument  made  to 
follow  it.  Its  entrance  into  the  bladder  is  assured  by  touching  its 
end  with  the  finger  in  the  rectum,  the  penis  is  stretched,  and  the 

/ 


lOO 


SURGICAL  AFFECTIONS    OF    THE    URETHRA. 


bladder  carefully  pushed  down  to  the  end  of  the  groove  dividing 
every  constriction  or  obstructing  tissue  before  it.     In  withdrawing       I 
the  instrument  every  precaution  must  be  taken  to  prevent  laceration 


of  healthy  tissue.     The  blade  must  be  kept  exactly  on  the  median 
line  and  the  penis  held  tense. 

Strictures  in  the  anterior  or  pendulous  urethra  the  calibre  of 


INSTRUMENTS  FOR  OPERATION  UPON  THE  URETHRA.      lOI 

which  is  1 6  F.  or  over,  will  permit  the  passage  of  the  Civiale 
URETHROTOME  which  is  Very  useful  in  some  cases.  This  instru- 
ment has  a  bulb  at  its  distal  end  with  a  concealed  blade 
which  is  quickly  drawn  out  by  pressing  on  a  spring  near  the 
handle. 

The  Otis  dilating  urethrotome  is  of  service  in  certain  cases 
when  skillfully  handled.  The  stricture  to  which  this  is  best  suited 
should  be  from  i6  to  20  F.  in  calibre. 

HoRWiTz's  DILATING  URETHROTOME.  (For  description  and  tech- 
nic  see  page  109.) 

Pedersen  has  devised  a  tunnelled  and  grooved  sound  and 
CATHETER,  the  curve  of  which  is  of  the  same  radius  as  the  standard 
urethral  sound,  but  one  inch  shorter.  This  decrease  in  length  has 
been  compensated  for  by  an  increase  of  one  inch  in  the  length  of  the 
shank.  The  object  and  advantage  of  the  short  curve  lie  in  the  fact 
that  there  is  very  much  less  leverage  on  the  face  of  a  stricture  in  a 
short  curve  than  in  a  long  curve,  thus  lessening  the  danger  of  in- 
juring the  filiform  and  of  making  false  passages  in  the  urethra. 
The  taper  of  the  curve  is  uniform  from  its  base  to  its  tip  and  regu- 
larly includes  six  sizes  from  No.  12  F.  upward.  The  length  of  the 
tunnel  secures  the  sounds  from  twisting,  breaking,  or  cutting  the 
filiform. 

The  technic  of  employing  these  instruments  is  as  follows: 
After  the  filiform  has  been  inserted  in  the  usual  manner,  the  6  F. 
catheter  is  passed  over  the  filiform,  the  bladder,  if  distended,  is 
partially  evacuated  through  the  silver  catheter,  or,  if  empty,  is 
moderately  filled  with  any  mild  antiseptic  solution,  such  as  boric 
acid,  permanganate  of  potash,  Thiersch  or  silver  nitrate  solution. 
The  catheter  is  then  removed,  leaving  the  filiform  in  situ,  and  the 
sounds  are  taken  in  order,  beginning  with  8  F.  and  gently  passed 
over  the  filiform  through  the  stricture  until  that  size  is  reached  which 
the  patient  states  to  be  moderately  painful.  The  sound  is  left  in 
situ  for  ten  or  fifteen  minutes  in  order  to  get  the  full  benefit  of  the 
dilatation.  After  this  the  filiform  and  sound  are  removed  and  the 
patient  is  allowed  to  evacuate  the  contents  of  his  bladder.     If  the 


I02  SURGICAL  AFFECTIONS    OF   THE    URETHRA. 

contents  of  the  bladder  be  urine,  as  in  cases  of  distention,  the  sound 
is  removed  and  the  filiform  is  left  in  place,  and  the  silver  catheter  is 
then  again  passed  and  the  bladder  carefully  washed  with  rather  hot 
antiseptic  fluid,  some  of  which  is  left  in  the  bladder  to  prevent 
bleeding,  such  as  sometimes  occurs  when  an  overdistended  bladder 
is  emptied. 

An  opening  may  be  thus  effected  to  enable  the  passage  of  a  sound 
20  to  24  F.  Dilatation  must  be  persisted  in  for  at  least  once  a 
week  for  a  considerable  period  thereafter.  Overdilatation  is  some- 
times advised,  but  is  always  liable  to  recontraction. 

Treatment  of  Strictures  of  the  Deep  Urethra. — The  method 
of  treatment  in  contractions  at  or  beyond  the  bulbo-membranous 
junction  (B.  M.  J.)  depends  entirely  on  the  density  of  the  stricture. 
The  soft  or  semi-fibrous  variety  should  never  be  operated  upon 
until  every  other  procedure  has  been  tried  and  has  been  un- 
successful. 

Before  any  operation  is  performed  in  the  urethra,  the  condition  of 
the  bladder  and  kidneys  should  be  ascertained  by  careful  examina- 
tion of  the  urine — to  determine  the  presence  of  albumin  and  casts 
and  the  percentage  of  urea.  The  amount  of  urine  voided  in  24 
hours  should  also  be  noted.  Then  by  means  of  a  urethrometer  and 
the  bulbous  bougie  the  nature,  position,  and  calibre  of  the  stricture 
are  to  be  established. 

The  various  methods  of  treating  stricture  in  the  posterior  urethra 
are  as  follows: 


I.  Dilatation 


Gradual, 
Co  tinuous, 
Rapid, 
^  Modified  Rapid. 

2.  Internal  Urethrotomy,  Maisonneuve. 

3.  External  Urethrotomy  (For  Drainage). 

4.  Retrograde  Catheterization. 

5.  a.  External  Urethrotomy  (Gouley's  Op.)- 

b.  External  Urethrotomy,  with  a  guide   (Syme's  Op.). 

6.  External  Urethrotomy,  without  a  guide  (Horwitz's  Op.). 

7.  External  Urethrotomy,  without  a  guide  (V/heelhouse,  Op.) 


INSTRUMENTS  FOR  OPERATION  UPON  THE  URETHRA.      IO3 

8.  External   Urethrotomy,    without   any   instrument   in    the   urethra 

(Cock's  Op.). 

9.  External   Urethrotomy,   without    any   instrument   in    the   urethra 

(Gibson's). 

10.  DivuLsiON  or  Rupture. 

11.  Electrolysis. 

Gradual  Dilatation. — The  indication  for  this  method  of  pro- 
cedure is  where  the  stricture  has  not  progressed  beyond  the  semi- 
fibrous  stage.  The  advantages  are  that  it  may  be  easily  performed 
and  is  attended  with  little  or  no  pain.  It  is  always  good  practice 
to  attempt  at  least  to  restore  the  normal  calibre  of  the  urethra  by 
gradual  dilatation.  The  introduction  of  the  sound  or  bougie  must 
be  gentle,  starting  with  an  instrument  just  large  enough  to  pass 
through  the  stricture  comfortably.  This  should  be  done  every 
third  or  fourth  day,  passing  the  same  size  bougie  two  or  three  times, 
then  advancing  to  the  next  number  and  so  on.  It  is  well  in  the 
beginning,  especially  when  the  calibre  of  the  urethra  is  10  or  12  F., 
to  use  the  olivary  flexible  bougie,  until  18  or  20  is  reached,  and  then 
the  conical  steel  bougie  should  be  employed,  increasing  as  the  condi- 
tion indicates  gradually  up  to  32  F.  and  continuing  with  this  number 
until  it  is  passed  easily  and  without  undue  resistance.  The  un- 
toward effects  or  complications  of  gradual  dilatation  are  fever  and 
chills,  inflammation,  urethral  hemorrhage,  and  spasmodic  retention. 
Should  any  of  these .  occur,  the  treatment  must  be  temporarily 
abandoned  until  the  complication  is  overcome  by  proper  treatment. 

Continuous  Dilatation. — When  the  stricture  has  contracted 
down  to  a  point  where  with  great  difficulty  the  filiform  is  passed, 
it  is  allowed  to  remain  in  situ  until  the  tissues  relax  and  allow  the 
passage  of  a  larger  instrument. 

Rapid  Dilatation. — Is  often  resorted  to  after  the  filiform  is 
passed  through  the  stricture  as  a  guide  for  the  tunnelled  sound, 
thus  gradually  increasing  the  number  until  12  or  14  F.  is  reached. 
The  result  obtained  by  this  process  is  only  temporary  as  a  rule, 
therefore  it  must  be  followed  either  by  gradual  dilatation  or  the 
more  radical  method  of  internal  and  external  urethrotomy  according 
to  the  densitv  of  the  stricture. 


I04  SURGICAL  AFFECTIONS    OF   THE   URETHRA. 

Modified  rapid  dilatation  is  the  treatment  preferred  by  many 
surgeons  for  strictures  of  small  calibre  in  the  membranous  urethra. 
It  is  especially  valuable  in  strictures  which  are  not  resilient,  irritable, 
or  nodular.  The  advantages  claimed  for  it  are:  that  there  is  less 
tendency  to  relapse;  is  free  from  complications;  is  attended  with  but 
little  or  no  danger  to  life,  and  the  amount  of  bleeding  is  practically 
nil.  The  technic  as  given  by  Orville  Horwitz  is  as  follows:  The 
urethra  is  flushed  with  a  4  per  cent,  boric  acid  solution  and  a  steril- 
ized filiform  bougie  passed  and  tied  in  place.  The  patient  is  kept 
in  bed,  given  urotropin  internally,  and  the  urethra  irrigated  daily 
for  three  days,  at  thfe  end  of  which  time  the  patient  is  ready  for 
operation.  The  anaesthetic  having  been  administered,  the  urethra 
is  again  washed  with  a  1-20,000  mercuric  chloride  solution.     The 


Fig.   29. — Thompson  dilator. 

Thompson  dilator  (Fig.  29)  is  then  passed  over  the  filiform  and 
through  the  obstruction,  when  by  means  of  a  thumb-screw  attached 
to  the  handle  of  the  instrument  the  blades  are  separated  to  a  slight 
degree;  after  remaining  in  this  position  for  about  a  minute  they  are 
again  approximated.  This  procedure  of  alternate  separation  and 
approximation  is  to  be  repeated  several  times.  Each  time  separat- 
ing the  blades  of  the  instrument  to  a  wider  degree,  until  the  stricture 
is  enlarged  sufiiciently  to  allow  of  the  insertion  of  the  Gross  dilator 
(Fig.  30),  the  calibre  of  which  is  18  F.  each.  The  Thompson  instru- 
ment is  now  withdrawn  and  the  Gross  dilator  inserted,  with  which 
the  calibre  of  the  urethra  is  then  brought  to  the  full  size  of  the  canal, 
which  has  been  previously  ascertained  by  means  of  a  bougie  a  boule. 
After  the  Gross  instrument  is  removed,  a  full  size  conical  steel 
bougie  is  passed  to  determine  whether  all  the  obstruction  has  been 
overcome.  This  condition  having  been  found,  the  urethra  is 
irrigated  with  a  1-20,000  mercuric  chloride  solution  and  a  sterilized 


INSTRUMENTS  FOR  OPERATION  UPON  THE  URETHRA.      105 


catheter  passed  and  tied  in  place.  A  small  quantity  of  boric  acid 
solution  is  then  injected  into  and  left  remain  in  the  bladder.  The 
patient  is  kept  in  bed  about  four  days,  sub- 
sequently the  urethra  and  bladder  irrigated 
daily,  and  the  catheter  removed  on  the  third 
day.  A  full  size  conical  steel  bougie  is  then 
passed  and  the  patient  may  resume  his  voca- 
tion the  following  ^  day,  continuing  with  the 
bougie  twice  a  week  for  about  six  weeks,  then 
once  a  week  every  other  week,  etc. 

The  CONTRAINDICATIONS  to  this  method  of 
treatment  are  in  the  aged  or  those  suffering 
from  diseases  of  the  kidney,  hence  the  impor- 
tance of  careful  microscopic  and  chemical  ex- 
amination of  the  urine,  preceding  the  operation ; 
urinary  fistulae  and  abscess  of  the  perineum 
render  this  method  inapplicable.  In  patients 
contemplating  marriage  at  an  early  date,  this 
operation  should  not  be  advised. 

Internal  Urethrotomy. — When  performed 
in  appropriate  cases  by  means  of  the  Maison- 
neuve  instrument  it  is  often  productive  of  much 
good.  It  is  particularly  indicated  in  cases  of 
fibrous  stricture  at  or  near  the  bulbo-membra- 
nous  junction.  The  preparation  of  the  patient 
in  all  operations  upon  the  urethra  is  practically 
the  same,  and  is  as  follows:  The  patient  should 
be  put  in  best  possible  physical  condition,  given 
tonics,  etc.,  if  necessary.  The  urine  should 
be  carefully  examined.  The  bladder  should 
be  treated  if  there  be  any  existing  disease,  and 
previous  to  the  operation  be  irrigated  with  hot 
boric  acid,  salt  or  permanganate  solutions.  A  day  or  two  prior  to 
the  operation  the  patient  should  be  kept  in  bed,  kept  on  a  light  diet 
and  an  enema  given  the  night  before.     The  patient  having  been 


Fig.  30. — Gross  dilator. 


Io6  SURGICAL  AFFECTIONS    OF    THE    URETHRA. 

thus  prepared  is  etherized,  placed  in  the  recumbent  posture.  The 
fihform  guide  of  the  Maisonneuve  instrument  is  then  passed  down 
the  urethra  and  into  the  bladder,  followed  by  the  groove  conductor 
and  the  knife  up  to  the  point  of  coarctation.  The  penis  is  then  held 
straight  and  tense,  the  knife  slowly  but  firmly  pushed  down,  direct- 
ing the  blade  of  the  instrument  toward  the  roof  of  the  urethra  in  a 
median  line.  It  is  well  for  the  surgeon  to  make  sure  of  the  position 
of  the  instrument  by  feeling  the  staff  of  the  instrument  with  the 
linger  in  the  rectum.  The  incision  should  be  made  up  to  a  calibre 
of  20  to  21  F.  After  this  is  accomplished  the  instrument  is  with- 
drawn and  a  soft  rubber  catheter  is  passed  down  the  urethra  into 
the  bladder  to  drain  off  any  of  the  contained  urine,  and  then  to  inject 
by  means  of  a  hand  syringe  about  4  to  6  drams  of  a  weak  silver 
solution  (i  to  4000)  and  allow  to  remain  until  the  patient  voids 
his  urine.  Two  or  three  days  later  this  injection  should  be  re- 
peated and  then  gradual  dilatation  may  be  commenced,  continu- 
ing up  until  a  calibre  of  30  to  32  F.  is  reached. 

Otis's  dilating  URETHROTOME  is  a  very  satisfactory  instrument 
used  in  performing  an  internal  urethrotomy.  -The  exact  location  of 
the  stricture  having  been  determined  this  instrument  is  passed  down 
to  a  point  about  one-half  inch  behind  the  stricture.  The  blades 
are  then  separated  until  tension  of  the  stricture  is  felt.  The  cutting 
blade  is  now  withdrawn  and  then  separated  to  the  required  extent. 
After  this  is  accomplished,  the  blades  are  brought  together  again, 
and  the  instrument  withdrawn.  It  is  then  well  to  explore  the  urethra 
with  a  full  size  bougie,  so  as  to  determine  whether  the  stricture  has 
been  sufficiently  divided.  After  this  the  urethra  should  be  irrigated 
with  a  hot  saturated  solution  of  boric  acid,  the  patient  put  to  bed, 
and  if  there  be  much  hemorrhage,  cold  applications  made  to  the 
part.  In  the  average  case  the  enlargement  of  the  urethra  secured, 
by  either  the  Maisonneuve  or  Otis  urethrotome,  should  be  of  a 
calibre  of  30  to  32  F.  The  after-treatment  is  largely  symptomatic, 
meeting  the  indications  as  they  arise.  The  bromides  may  be  given 
for  their  sedative  effect,  salol  to  keep  the  urine  bland  and  antiseptic, 
etc.     By  far,  in  the  larger  number  of  cases  in  which  internal  ure- 


INSTRUMENTS  FOR  OPERATION  UPON  THE  URETHRA.      107 

throtomy  has  been  done,  the  result  is  permanent,  hence  the  sub- 
sequent use  of  bougie  is  usually  unnecessary  as  a  routine  measure. 
External  Urethrotomy. — The  usual  steps  of  preparing  a  patient 
having  been  taken,  he  is  etherized  and  placed  in  the  lithotomy 
position.  The  grooved  sound  is  passed  into  the  bladder,  and  the 
scrotum  is  held  out  of  the  way  by  an  assistant  who  at  the  same  time 
steadies  the  sound.  An  incision  is  made  for  about  two  inches  into 
the  tissues,  overlying  the  convexity  of  the  staff.  The  urethra  is 
thus  exposed  and  a  small  incision  made  into  it.  The  bladder  is  then 
drained  with  a  large  catheter  or  perineal  tube  inserted.  This  is 
anchored  to  the  skin  by  a  suture  to  hold  it  in  place.  This  is  often 
called  the  "boutonniere."  This  operation  can  also  be  performed 
for  the  purpose  of  removing  calculi  or  concretions  lodged  in  the 
prostatic  urethra. 


Fig.  31. — Arnott's    small  grooved  silver  probe. 

External  Urethrotomy  without  a  Guide,  ''Gouley's  opera- 
tion." The  patient  being  anaesthetized  and  placed  in  the  lithotomy 
position,  the  filiform  is  inserted  through  the  stricture  and  over  this 
the  Gouley  tunnel  catheter  is  passed.  The  assistant  holds  the  end 
of  the  sound  exactly  in  the  median  line  at  right  angle  to  the  body, 
at  the  same  time  holding  the  scrotum  out  of  the  way.  An  incision 
is  then  made,  carefully  dividing  the  tissues,  layer  by  layer,  from  the 
base  of  the  scrotum  to  within  an  inch  of  the  anus.  Guided  by  the 
sound  the  surgeon  feels  for  the  urethra  and  cuts  carefully  downward 
for  about  an  inch,  entering  the  canal.  After  the  hemorrhage  has 
been  controlled  a  ligature  two  feet  long,  to  be  held  by  the  assistants, 
is  applied  and  used  as  a  retractor.  A  small  grooved  silver  probe 
with  a  handle  which  can  be  bent  to  any  angle  is  passed  through  the 
opening  into  the  bladder  from  which  Gouley's  beaked  bistoury  is 


Io8  SURGICAL  AFFECTIONS    OF   THE    URETHRA. 

passed  and  the  stricture  incised  on  its  upper  surface.  The  groove 
is  then  inverted  by  simply  turning  the  probe  and  an  incision  made 
on  the  floor  of  the  stricture.  The  stricture  tissues  having  been  thus 
divided,  Teale's  probe  gorget  (Fig.  32)  is  passed  which  readily 
allows  the  insertion  of  the  catheter  and  perineal  tube,  through  which 
the  bladder  is  then  thoroughly  irrigated.  This  tube  is  allowed  to 
remain  in  the  wound  for  5  or  6  days,  and  the  bladder  irrigated  2  or 
3  times  daily. 

The  tube  is  held  in  place  by  means  of  a  ligature  to  the  edge  of  the 
wound,  around  the  end  of  which  is  well  protected  with  iodoform 
gauze  and  a  firm  dressing  held  in  place  by  a  retentive  bandage. 


Fig.  32. — Teale's  probe  gorget. 

Rarely  does  urinary  fever,  sepsis,  or  hemorrhage  follow  these  opera- 
tions when  performed  with  the  proper  antiseptic  precautions.  The 
hemorrhage  which  sometimes  follows  is  readily  controlled  by 
pressure. 

Syme's  Operation. — The  technic  of  this  method  is  practically 
the  same  as  the  Gouley,  with  the  exception  of  the  instrument  in  the 
urethra,  which  is  known  as  the  Syme's  staff.  This  instrument,  how- 
ever, is  more  dangerous  than  the  Gouley  and  more  liable  to  cause 
false  passages  in  the  hemorrhage.  The  difficulty  therefore  renders 
it  less  useful. 

External  Urethrotomy  without  a  Guide  through  the  Stricture 
(Wheelhouse's  Operation). — The  patient  being  etherized  and 
in  the  lithotomy  position,  the  Wheelhouse  staff  (Fig.  33)  is  carefully 
passed  down  to  the  stricture,  with  its  groove  facing  the  floor  of  the 
urethra.  An  incision  into  the  perineum  is  made,  the  tissues  care- 
fully dissected  until  the  urethra  is  reached. 


INSTRUMENTS  FOR  OPERATION  UPON  THE  URETHRA.      lOQ 

The  canal  is  then  opened  on  the  groove  of  the  staff.  The  staff 
is  then  withdrawn  to  the  upper  angle  of  wound  and  then  turned  so 
that  its  button  puts  the  canal  further  on  a  stretch. 

By  this  means  the  part  is  well  exposed  and  the  surgeon  has  little 
or  no  difficulty  in  forcing  the  grooved  probe  or  gorget  into  its  open- 
ing, traversing  the  stricture  into  the  bladder.  The  stricture  is  then 
divided  on  its  upper  and  lower  wall  by  means  of  a  probe-pointed 
bistoury.  The  incision  thus  made  into  the  stricture  usually  affords 
sufficient  access  to  the  bladder,  but  this  opening  may  be  further 
dilated  by  the  surgeon  inserting  his  forefinger  into  it.  Subse- 
quent proceedings  are  the  same  as  described  in  the  Gouley's 
operation,  (q.  v.). 


Fig.  z2>- — Wheelhouse's  staff. 

External  Urethrotomy  without  a  Guide  (Horwitz's  Opera- 
tion for  Perineal  Section). — In  cases  where  difficulty  is  en- 
countered in  finding  the  urethra  and  in  operations  for  stricture  and 
ruptured  urethra  Orville  Horwitz  has  devised  an  ingenious  instru- 
ment which  considerably  modifies  the  Wheelhouse  operation.  The 
method  is  simplified  by  the  substitution  of  a  perineal  staff. 

The  TECHNic  is  as  follows:  By  means  of  a  dilator  (Fig.  34),  the 
passage  of  which  is  facilitated  by  threading  it  over  a  filiform  bougie, 
until  the  instrument  is  arrested  at  the  point  of  coarctation.  An 
assistant  turns  the  thumb-screw  separating  the  blades  as  shown  in 
Fig.  35,  the  calibre  of  which  is  noted  by  an  indicator  on  the  handle 
of  the  staff. 

The  operator  is  then  better  enabled  to  make  an  incision  directly 
overlying  it.  The  advantages  claimed  for  this  instrument  are  that 
it  not  only  fixes  the  urethra  in  one  position  but  is  made  prominent 
by  the  expanded  blades. 

External  Urethrotomy  without  a  Guide  (Cock's  Operation 
for  Perineal  Section). — This  operation  is  advisable  where  the 
perineum  and  scrotum  become  swollen,  either  as  a  result  of  an  old 


no 


SURGICAL  AFFECTIONS    OF    THE    URETHIL\. 


long  Standing  stricture  or  traumatism  in  which  the  urethra,  anterior 
to  the  stenosis,  is  practically  obliterated  and  therefore  impermeable 
to  instruments. 

The  patient  being  etherized,  a  last  attempt  should  be  made  to 


fe 


m 


iiv 


pass  an  instrument  through  the  stricture  in  the  hope  of  paving  a  way,, 
and  providing  a  guide.  Should  this  be  unsuccessful  he  is  placed  in 
the  lithotomy  position.  The  operator,  seated  in  front  of  the  patient, 
inserts  the  left  forefinger  into  the  rectum  and  its  tip  held  firmly 


INSTRUMENTS  FOR  OPERATION  UPON  THE  URETHRA.       TJI 

against  the  apex  of  the  prostate.  Then  by  means  of  a  double  edge 
knife  or  ordinary  scalpel,  with  the  cutting  edge  of  the  blade  upward, 
an  incision  is  made  into  the  raphe,  about  an  inch  anterior  to  the 
anus,  and  carried  forward  in  the  direction  of  the  finger  tip,  thus 
making  a  vertical  incision.  The  bladder  is  then  entered  through 
the  membranous  urethra,  and  a  large  soft  rubber  catheter  intro- 
duced and  retained  by  a  suture  to  the  outer  edge  of  the  wound. 
Subsequently  the  bladder  by  this  means  is  frequently  irrigated  and 
within  a  few  days  the  extravasation  and  swelling  in  the  perineum 
subsides  and  the  urethra  is  re-established,  which  will  then  probably 
permit  instrumentation. 

Retrograde  Catheterization.— Conditions  in  which  there  has 
been  rupture  of  the  urethra  and  in  which  it  is  impossible  to  find  the 
proximal  end  of  the  canal,  retrograde  catheterization  must  be 
resorted  to.  The  operation  is  as  follows:  A  small  suprapubic 
incision  is  made  on  the  median  line,  sufficiently  large  enough  to 
allow  locating  the  internal  vesical  orifice  by  means  of  the  index 
finger.  This  being  the  proximal  end,  the  catheter  may  be  easily 
passed  through  the  distal  portion  of  the  urethra.  The  catheter  is 
allowed  to  remain  for  the  purpose  of  draining  the  bladder  or  to  act 
as  a  guide  in  approximating  the  torn  ends  of  the  urethra,  which  may 
be  sutured  or  allowed  to  heal  by  granulation. 

Rupture  or  divulsion  is  a  relic  of  surgical  barbarism  and  is 
hardly  worthy  of  mention.  It  consists  simply  of  a  rapid  and  forcible 
dilatation,  with  the  object  of  rupturing  the  tissues  and  in  most 
instances  followed  by  inflammation,  causing  it  to  become  resilient 
and  irritable. 

Electrolysis. — This  method  has  few  advocates.  The  object  is 
to  decompose  and  permit  the  absorption  of  the  morbid  tissues,  by 
means  of  electricity.  The  method  is  attended  with  very  little  pain 
and  practically  no  hemorrhage,  and  is  never  followed  by  any  septic 
complications.  Fort's  electrolyser  has  been  recommended  and  is 
only  useful  in  cases  where  the  Maisonneuve  operation  is  indicated. 

Regarding  the  use  of  the  Ouden  current  and  galvano -cautery  in 
the  treatment  of  strictures  is  too  early  to  say,  but  is  well  worthy  of 


112  SURGICAL  AFFECTIONS    OF   THE    URETHRA. 

trial  and  experimentation  so  as  to  determine  their  value  in  these 
cases. 

Urethrectomy. — In  severe  cases  of  stricture  of  the  traumatic 
and  inodular  type,  this  method  may  be  employed.  The  entire 
stricture  or  mass  is  excised  and  the  ends  of  the  urethra  are  approxi- 
mated and  sutured,  or  a  catheter  may  be  inserted,  and  the  cut  ends 
allowed  to  heal  by  granulation.  This  unfortunately  is  almost 
invariably  followed  by  cicatricial  contraction. 

Retention  of  Urine. — This  condition  may  occur  as  a  result  of 
alcoholic  excesses,  exposure  to  cold  and  wet,  sexual  excesses,  great 
physical  exertion,  in  the  declining  stage  of  urethritis,  and  impacted 
calculus  or  foreign  body,  also  from  stricture,  enlarged  prostate, 
atony  of  the  bladder,  pressure  from  tumors, -and  unskillful  instru- 
mentation of  the  urethra.  The  inability  to  expell  the  urine  con- 
tained in  the  bladder  may  be  partial  or  complete,  and  is  usually  due 
to  a  sudden  congestion  of  the  urethral  mucous  membrane,  or  spasm 
of  the  compressor  urethrae  muscle. 

Symptoms. — On  percussion,  the  bladder  being  found  distended, 
there  will  be  more  or  less  local  pain.  The  bladder  will  be  distended 
and  distinctly  felt  in  the  hypogastric  region,  extending  up  toward 
the  umbilicus.  It  is  more  or  less  sensitive  to  touch.  Dulness  will 
be  found  on  percussion.  If  this  is  not  soon  relieved  the  pain 
becomes  intense  and  constitutional  disturbances  more  marked. 

There  is  usually  an  urgent  desire  to  empty  the  bladder,  attended 
with  tenesmus,  probably  some  rise  in  temperature  and  chills,  and 
later  a  slight  dribbling  of  urine  as  a  result  of  an  atony  of  sphincters. 
Cases  have  been  reported  where  the  condition  has  been  allowed  to 
go  on  for  several  days,  in  which  rupture  of  the  bladder,  followed 
by  peritonitis  and  gangrene,  or  abscesses  of  the  kidney  have  ensued. 
Death  from  uraemic  poisoning  may  also  ensue  in  neglected  cases. 

Diagnosis. — The  only  other  conditions  with  retention  confounded 
are  pregnancy  and  ascites. 

Treatment. — This  depends  largely  upon  the  cause,  the  knowl- 
edge of  which  should  be  our  principal  guide.  Where  the  retention 
is  due  to  urethritis,  the  urethra  should  be  irrigated  and  a  flexible 


INSTRUMENTS  FOR  OPERATION  UPON  THE  URETHRA.      II3 

catheter  20  F.,  well  lubricated,  should  be  passed  until  it  meets  with 
obstruction.  At  this  point  it  is  allowed  to  remain  for  a  few  minutes, 
depending  on  the  condition,  if  it  be  spasmodic,  to  relax  itself.  If 
this  is  unsuccessful  the  patient  must  be  given  a  hot  bath,  followed 
by  1/6  gr.  of  morphia,  and  10  gr.  quinine,  then  put  to  bed  and  a  hot 
water  bag  applied  over  the  hypogastric,  where  the  retention  results 
from  urethral  stricture,  this  knowledge  having  been  ascertained  by 
a  careful  history.  Relief  may  be  obtained  by  the  use  of  either  the 
Thompson  or  Bumstead  retention  catheter  or,  what  is  still  better,  in- 
serting the  filiform  after  it  has  passed  through  the  stricture,  followed 
by  a  small  Gouley  tunnelled  catheter  into  the  bladder,  by  which  the 
urine  may  be  drained  off.  Hot  rectal  injections,  suppositories  of 
opium  and  b  Jladonna  are  also  useful  as  supplementary  measures. 
If  an  impacted  calculus  be  the  cause  it  must  be  removed.  The 
bowels  should  be  opened  as  soon  as  possible,  the  urine  rendered 
bland  and  unirritating,  sedatives  administered,  and  the  use  of  stim- 
ulants interdicted.  Where  bladder  distention  has  been  great,  about 
half  of  the  urine  must  be  drained  off  at  first,  and  several  hours  later 
the  remainder,  as  there  is  liability  to  paralysis  of  the  bladder  due  to 
sudden  collapse  of  the  overdistended  walls.  In  those  neglected 
cases,  where  there  has  been  some  vesical,  urethral,  and  renal  con- 
gestion, the  vessels  at  first  become  suddenly  depleted,  then  when 
the  circulation  is  re-established  hemorrhages  occur,  resulting  in 
death. 

Newly  born  infants  may  suffer  with  retention  in  consequence  of  an 
imperforate  prepuce  or  imperforate  meatus.  In  the  former  case  it 
may  be  necessary  to  circumcise  the  patient  and  in  the  latter  case  a 
'meatus  must  be  made,  introducing  a  catheter  if  necessary.  If  it  is 
due  to  a  cyst  in  the  sinus  pocularis,  as  is  frequently  the  case,  it  will 
be  at  once  relieved  by  passing  a  small  probe,  rupturing  the  wall  of 
the  s,ac. 

Tapping  of  the  Bladder. — Not  infrequently  when  every  means 
of  reaching  the  bladder  has  failed,  it  becomes  necessary  to  resort  to 
aspiration.  The  instruments  employed  for  this  purpose  are  the 
Hayden's  aspirator  and  trocar  (see  Fig.  41,  p.  142),  or  ordinary  long 


114  SURGICAL   AFFECTIONS    OF    THE    URETHRA. 

trocar  and  cannula.  The  pubes  should  be  shaved  and  rendered 
surgically  clean.  The  instrument  having  been  carefully  sterilized 
is  inserted  about  one  inch  above  the  symphysis  in  the  middle  line, 
directing  it  downward  and  backward.  This  operation  may  be 
repeated  several  times  on  the  same  day  or  subsequent  days.  Points 
of  puncture  may  be  closed  over  with  flexible  or  iodoformized 
collodion. 

Extravasation  of  Urine. — This  dangerous  coniplication  usually 
occurs  as  a  result  of  some  severe  strain  upon  the  urethral  walls,  in 
cases  of  tight  stricture.  The  thin  urethral  walls  behind  the  stricture 
(resulting  from  repeated  efforts  to  expel  the  urine)  forms  a  pouch- 
like dilatation.  After  some  violent  efforts  this  weak  tissue  gives 
way  and  the  urine  escapes  into  the  urethral  tissues.  Abscesses 
situated  anywhere  along  the  course  of  the  urethra  may  also  predis- 
pose to  extravasation  of  urine  into  the  perineum.  The  seat  of  the 
rupture  may  be  either  as  far  back  as  the  anterior  leaflet  or  the  trian- 
gular ligament,  between  these  folds  (membranous  urethra) ,  or  behind 
the  posterior  leaflet  of  the  triangular  ligament;  either  at  the  junction 
of  the  urethra  or  in  the  prostatic  urethra  itself. 

Rupture  of  the  Anterior  Urethra. — When  the  rupture  occurs 
in  front  of  the  triangular  ligament  the  urine  burrows  through  the 
cellular  tissues  of  the  scrotum  and  penis,  and  extends  upward 
toward  the  umbilicus.  This  is  rather  rare,  however,  and  may  be 
due  to  impacted  calculus  as  well  as  stricture.  There  is  always 
considerable  swelling  accompanying  these  conditions.  The  urine 
is  prevented  from  escaping  into  the  pelvic  cavity  or  from  diffusing 
itself  down  the  thighs  by  the  firm  attachment  of  the  perineal  fascia 
to  the  ischlopubic  line.  In  extreme  cases  the  extravasation  may 
extend  up  as  far  as  the  umbilicus.  Unless  this  condition  is  imme- 
diately relieved,  abscesses  rapidly  form,  the  tissues  become  gangren- 
ous and  slough,  resulting  in  urinary  fistulae.  The  danger  of  sepsis 
is  always  imminent,  and  unless  an  operation  is  immediately  per- 
formed, death  may  promptly  ensue. 

Rupture  of  Posterior  Urethra. — When  the  rupture  occurs 
posterior  to  the  triangular  ligament,  the  urine  burrows  into  the  deep 


INSTRUMENTS  FOR  OPERATION  UPON  THE  URETHRA.      II5 

layer  of  the  perineal  fascia  and  into  the  prevesical  space,  forming  a 
swelling  above  the  symphysis,  or  it  may  find  its  way  into  the  recto- 
vesical space  with  a  consequent  swelling  in  the  perineum.  The 
diagnosis  is  usually  confirmed  by  rectal  examination.  When  the 
extravasation  takes  place  between  the  folds  of  the  triangular  liga- 
ment, the  urine  burrows  into  the  perineum  and  scrotum  or  may  take 
a  backward  turn  into  the  pelvis,  where  it  can  be  detected  as  a 
doughy  mass  by  a  digital  examination  of  the  rectum. 

Symptoms. — Usually  there  is  a  sudden  gush  of  urine,  but  some- 
times the  extravasation  may  take  place  quite  slowly.  The  patient 
feels  a  sensation  of  ''something  giving  way,"  with  a  feeling  of 
temporary  relief,  but  when  an  attempt  is  made  to  urinate  he  finds 
himself  unable  to  do  so.  Constitutional  disturbances  soon  become 
manifest.  There  is  a  feeling  of  weakness,  nausea,  fever,  and  chills. 
Upon  examination  the  scrotum  will  be  found  distended  and  swollen, 
extending  toward  the  abdomen.  The  skin  is  soggy  and  discolored, 
soon  this  changes  to  a  purplish  color  and  if  allowed  to  continue  will 
develop  into  gangrene,  with  sloughs  of  tissue  coming  away,  often 
so  far  as  to  expose  the  testicles.  Unless  relieved  by  immediate 
operation  the  patient  passes  into  fatal  coma  from  uraemia  and 
septicaemia. 

Treatment.— Urinary  extravasations  demand  the  performance  of 
an  immediate  external  urethrotomy  and  the  bladder  drained  and 
irrigated  through  a  catheter  or  perineal  tube,  so  as  to  prevent  any 
further  infiltration  of  urine  into  the  tissues.  Free  incision  should  be 
made  into  any  of  the  swollen  tissues,  all  sloughs  carefully  removed, 
and  the  part  copiously  irrigated  with  a  hot  bichloride  solution  (i  to 
5000),  or  saline  solution.  Any  collections  of  pus  should  be  opened, 
drained,  and  packed  with  iodoform  gauze.  Extravasations  into  the 
prevesical  space  demand  the  suprapubic  cystotomy  and  the  urine 
evacuated. 

Dressing  should  be  frequently  renewed  and  any  evidences  of 
shock  combated  by  the  usual  methods. 

Urethral  Fever.  Synonyms. — Urinary  fever,  urinary  infection, 
catheter  fever,  and  urinary  poisoning. 


Il6  SURGICAL  AFFECTIONS    OF    THE    URETHRA. 

Occurs  as  a  result  very  often  of  operations  upon  the  urethra  and 
bladder  or  prostate.  Symptoms  of  cystitis  more  or  less  observed, 
but  is  characterized  by  sudden  rise  in  temperature  preceded  or 
followed  by  a  chill.  It  occurs  in  forms,  acute  and  chronic.  The 
acute  form  may  be  noticed  after  gentle  instrumentation  of  the 
urethra  and  bladder. 

The  chills  will  usually  last  about  half  an  hour.  The  urinary 
secretion  is  lessened  and  in  a  few  hours,  when  the  temperature 
falls,  there  is  a  profuse  sweating  and  an  increase  in  the  amount  of 
urine  voided,  which  if  examined  will  be  found  to  contain  abundant 
urea  and  albumin.  The  rise  in  temperature  is  sudden  and  may 
reach  104  to  106  F.  This  condition  may  last  one  or  several  days 
and  may  recur  at  intervals."  The  chronic  form  is  mostly  observed  in 
old  patients,  suffering  from  stricture,  in  whom  there  is  a  coexisting 
disease  of  the  bladder,  kidney,  or  prostate  which  develops  insidiously. 
The  fever  may  be  continuous  or  intermittent.  The  course  of  the 
fever,  however,  is  prolonged,  the  patient  fails  in  health,  complains 
of  malaise  and  dyspepsia,  and  in  the  end  succumbs  to  uraemia  or 
septicaemia.     In  severe  cases,  there  is  usually  suppression  of  urine. 

Treatment. — In  order  to  avoid  urinary  fever,  all  operations  upon 
the  urethra,  prostate,  and  bladder  should  be  attended  with  strict 
antisepsis,  and  great  care  taken  in  the  matter  of  drainage  and  fre- 
quent irrigation.  In  a  mild  attack,  all  is  necessary  is  rest  in  bed, 
giving  the  patient  hot  drinks,  applying  external  heat,  and  giving 
him  salol  or  urotropin  as  urinary  antiseptics;  and  small  doses  of 
quinine  and  opium.  If  there  is  any  renal  impairment,  the  urine 
being  albuminous  or  bloody  or  suppression  occurs,  the  patient 
should  be  given  a  hot  bath  and  cups  applied  over  the  kidneys, 
plenty  of  diluent  drinks,  and,  internally,  large  doses  of  digitalin  ar 
tincture  of  digitalis.  If  there  be  any  shock  it  may  be  necessary  to 
resort  to  venous  transfusion. 


CHAPTER  V. 

MISCELLANEOUS  AFFECTIONS  OF  THE 
GENITOURINARY  ORGANS. 

Nocturnal  incontinence  of  urine  is  a  symptom,  not  a  disease. 
The  bladder  is  either  wholly  or  partially  unable  to  retain  its  contents. 
The.  age,  the  constitutional  state,  the  hygienic  surroundings,  the 
social  position,  the  past  and  present  history  of  the  patient  must  be 
taken  into  consideration  before  we  can  ascertain  the  etiology  of 
enuresis.  In  the  extremes  of  youth  and  senility,  nocturnal  incon- 
tinence of  urine  is  most  frequently  encountered.  Of  the  two, 
children  of  either  sex  up  to  the  age  of  sixteen  years  furnish  the 
larger  number  of  cases.  In  old  age  it  is  usually  due  to  atony, 
relaxation  or  paralysis  of  the  sphincters  at  the  vesical  outlet,  and  is 
frequently  associated  with  vesical  calculi  and  cystitis,  and  diseases 
of  the  prostate.  It  should  never  be  confounded  with  the  incon- 
tinence due  to  retention.  Nocturnal  incontinence  in  middle  life  is 
often  an  early  symptom  of  brain  or  cord  lesions,  e.g.,  tabes,  and 
therefore  must  be  treated  accordingly. 

In  children  it  is  usually  due  to  spasmodic  contractions  of  the 
detrusor  muscular  layer  of  the  bladder;  it  is  a  reflex  phenomenon 
due  to  an  increased  reflex  excitability  of  nervous  mechanism.  An 
examination  of  the  external  genitalia  will  frequently  reveal  the 
presence  of  seat  worms,  contracted  meatus,  contracted  or  adherent 
or  redundant  prepuce,  balanitis,  pruritus,  vulvitis,  or  allied  condi- 
tions, e.g.,  phimosis,  adherent  clitoris  in  females,  etc. 

Children  most  frequently  suffering  from  nocturnal  incontinence 
are  of  a  weak,  anaemic,  poorly  nourished  type,  the  majority  of  them 
being  from  the  poorer  classes.  As  they  grow  older  there  is  usually 
an  abatement  of  the  condition  and  it  disappears  entirely  at  about 
the  age  of  puberty. 

117 


Il8  MISCELLANEOUS  AFFECTIONS. 

Treatment. — In  all  forms  of  nocturnal  incontinence  rest  is  of 
prime  importance;  the  diet  must  be  restricted,  hygienic  measures 
supported,  and  personal  cleanliness  insisted  upon.  The  patient 
should  be  kept  in  bed  if  possible,  and  the  etiology  determined.  The 
urethra  and  bladder  must  be  examined  by  means  of  the  sound, 
endoscope,  cystoscope,  etc.,  also  rectal  examination  of  the  prostate 
and  vesicles.  Foods  that  are  easily  digested,  are  nourishing,  and  do 
not  cause  concentration  of  the  urine  are  indicated.  Acids  should  be 
restricted  and  larger  quantities  of  water  administered.  Particular 
care  must  be  paid  to  the  general  health  of  the  patient,  and  remedies 
that  will  promote  general  nutrition,  such  as  arsenic,  iron,  strychnine, 
and  cod  liver  oil  will  be  found  beneficial  in  a  large  majority  of  cases. 
The  use  of  coffee  and  milk  is  interdicted.  In  atony,  relaxation,  or 
paralysis  of  the  sphincters  of  the  bladder,  the  resulting  incontinence 
can  often  be  overcome  by  the  employment  of  one  drop  doses  of 
tincture  of  cantharides,  three  or  four  times  a  day,  well  diluted. 

In  such  cases  cantharides  act  almost  as  a  specific.  Liquor  potasii 
arsenitis  may  with  advantage  be  alternated  with  cantharides  in 
treating  nocturnal  incontinence  due  to  the  conditions  mentioned. 
The  galvanic  current  is  very  useful  in  overcoming  obstinate  cases. 
The  best  means  of  employing  it  is  by  the  use  of  a  urethral  electrode, 
the  same  to  be  introduced  up  to  the  bladder.  The  positive  pole  is 
to  be  placed  over  the  fourth  or  fifth  lumbar  vertebra  and  the  negative 
attached  to  the  urethral  electrode.  Only  a  very  mild  current  can 
thus  be  employed,  but  after  repeated  applications  decided  improve- 
ment will  be  noticed. 

When  nocturnal  incontinence  occurs  in  children  of  the  nervous 
type,  the  bromides  and  belladonna  are  useful.  When  any  prepara- 
tion of  belladonna  is  used  it  should  be  preceded  three  or  four  days 
by  the  frequent  administration  of  an  alkaline  diuretic. 

If  cystitis  is  the  cause  of  the  nocturnal  incontinence,  the  bladder 
must  have  absolute  rest.  This  is  best  accomplished  by  continual 
catheterism,  a  self-retaining  catheter  being  the  best  instrument  to 
employ.  The  bladder  should  be  thoroughly  irrigated  at  frequent 
intervals  with  hot  saline  solution  or  sterile  water.     Salol  admin- 


BACTERIURIA.  I  i  () 

istered  internally  will  also  do  good.  In  such  cases  the  urine  must 
be  rendered  nonirritating. 

When  incontinence  occurs  as  a  result  of  concentrated  or  highly 
acid  urine,  the  administration  of  an  alkaline  diuretic  every  three 
or  four  hours  will  relieve  the  condition.  Some  of  the  salts  of  potas- 
sium are  very  useful  in  cases  of  this  description.  The  acetate  of 
potassium  combined  with  the  bromide  of  potassium  will  be  found 
beneficial. 

If  the  incontinence  is  due  to  the  presence  of  seat  worms,  in  or 
around  the  genital  organs,  they  must  be  removed  and  personal 
cleanliness  enforced.  When  an  adherent  or  contracted  prepuce  is 
the  cause,  circumcision  must  be  performed.  If  contraction  of  the 
meatus  is  the  cause,  surgical  correction  of  the  abnormality  will 
relieve  the  incontinence.  Vulvitis  and  balanitis  are  frequently  the 
causes  of  nocturnal  enuresis  and  must  be  treated  by  the  local  appli- 
cation of  antiphlogistic  remedies. 

In  all  cases  of  nocturnal  incontinence  it  is  wise  to  examine  the 
urine  both  microscopically  and  chemically,  as  it  is  often  necessary 
to  determine  the  cause  by  exclusion. 

Atropine  in  enuresis  relieves  reflex  activity;  Holt  advises  i-iooo 
gr.  gradually  increased  to  i-ioo,  three  times  a  day. 

Fl.  ext.  ergot,  30  drops  three  times  a  day. 

Strychnia  i-ioo  gr.  three  times  a  day  in  children  4  or  5  years  old. 

Hyperaesthesia  of  bladder  may  be  relieved  by  tr.  hyocyamus. 

Epidural  injections  have  been  proposed  by  Cathelin,  Through 
its  opening  into  the  sacrum  the  sacral  canal  is  reached,  into  which 
the  injections  are  made  between  the  periosteum  of  the  vertebra  and 
the  dura-mater.  An  ordinary  needle  of  an  aspirating  syringe  is 
used  for  this  purpose.  Five  c.c.  of  sterile  salt  solution  are  given  in 
the  first  injection  and  at  intervals  of  about  a  week  gradually  in- 
creased to  ten  or  fifteen.  Good  results  have  been  obtained  by  this 
method  of  treatment. 

BACTERIURIA. 

Very  frequently  cases  are  met  with  in  which  the  urine  is  clear 


I20  MISCELLANEOUS  AFFECTIONS. 

only  slightly  turbid,  and  fetid,  in  which  the  patient  complains  of  no 
ill  feeling  nor  presents  any  symptoms  or  history  of  either  cystitis  or 
urethritis.  The  condition  of  the  urine  is  the  only  criterion.  This 
will  be  found  more  or  less  opaque,  with  a  distinct  cloud.  Its  odor 
strong,  fetid,  and  like  that  of  stale  fish,  and  is  due  simply  to  the 
presence  of  bacteria.  The  principal  microbe  most  commonly  found 
is  the  bacteria  coli  communa,  but  streptococci  and  bacillus  subtilis 
are  also  frequently  found. 

Treatment. — This  consists  in  irrigations  of  the  bladder  with 
oxycyanide  of  mercury  solution,  1-5000,  and  instillations  of  weak 
silver  solutions  into  the  deep  urethra.  Internally  urotropin  may 
be  given,  so  as  to  combat  the  infection  and  prevent  urinary  decom- 
position. 

Haematuria. — Presence  of  blood  in  the  urine  in  any  quantity  is 
always  most  significant  of  lesions  or  abnormalities  in  some  part  of 
the  urinary  apparatus.  The  urine  may  be  simply  tinged  from  the 
presence  of  a  very  small  amount  and  in  other  cases  the  quantity  may 
be  so  marked  as  to  give  it  a  deep  red  color  when  freshly  voided. 
The  blood  may  be  present  in  solution  or  clots  and  depends  largely 
on  the  source  of  the  hemorrhage.  The  microscope  will  differentiate 
between  the  haematuria  and  haemoglobinuria;  also  from  the  presence 
of  bile  pigments  or  from  the  action  of  drugs,  e.g.,  rhubarb  and  senna. 
The  origin  of  haematuria  may  be  deduced  with  a  practical  knowl- 
edge of  a  few  facts,  which  are  summarized  as  follows:  Oozing  of 
blood  from  the  meatus;  or  if  in  the  two  glass  test,  the  first  urine  is 
bloody  the  hemorrhage  is  from  the  anterior  urethra,  the  cause  of 
which  can  be  definitely  determined  by  the  endoscope. 

When  the  first  and  second  glasses  both  contain  blood  with  the 
history  of  increased  micturition,  tenesmus,  pain,  and  terminal 
haematuria,  or  blood  at  the  end  of  urination,  the  bleeding  is  from 
the  deep  urethra,  prostate,  seminal  vesicles,  or  neck  of  the  bladder. 
This  calls  for  the  use  of  the  endoscope,  cystoscope,  stone  searcher 
and  a  rectal  examination  so  as  to  definitely  localize  the  morbid  area. 

Hemorrhage  from  the  ureter  or  kidney  is  usually  indicated  by 
long  thin  clots  noted  in  the  urine  in  both  glasses.     With  this  there 


HEMORRHAGE    FROM   THE    URETHRA.  121 

will  be  the  usual  history  of  frequent  attacks  of  renal  colic,  and  shoot- 
ing lumbar  pains.  The  lumbar  region  and  abdomen  are  sensitive 
to  manipulation,  the  overlying  muscles  being  tense  and  resistant. 

Bleeding  from  the  bladder,  ureters,  or  kidneys  may  be  determined 
by  the  use  of  an  irrigating  cystoscopy  If  the  bladder  is  the  source 
of  the  hemorrhage  it  can  be  readily  seen.  If  the  kidneys  or  ureters 
are  the  seat  of  the  lesion  the  blood  will  be  seen  on  its  entrance  to  the 
bladder. 

Sometimes  even  these  methods  fail  to  localize  the  source,  when  it 
may  become  necessary  to  resort  to  what  is  known  as  the  resorption 
test,  which  is  based  upon  the  following  principles.  The  mucous 
membrane  normally  has  no  power  of  absorption,  therefore,  when 
the  bladder  is  irrigated  and  thoroughly  drained,  and  filled  with  a 
2  per  cent,  solution  of  potassium  iodide. 

In  from  15  to  20  minutes  later,  if  the  patient's  sputum  is  added  to 
a  starch  solution,  the  presence  of  iodine  will  be  indicated  if  it  is 
absorbed  by  the  diseased  area  in  the  bladder,  by  a  blue  reaction. 

History  of  traumatism  in  the  perineum,  e.g.,  kicks,  etc.,  indicate 
contusion,  laceration,  and  sometimes  rupture  of  the  urethra. 

Treatment. — The  patient  should  be  kept  quiet  as  possible,  and 
fluid  ext.  of  ergot  or  adrenalin  chloride  (i-iooo),  in  15  drop  doses, 
given  by  the  mouth  every  third  hour  until  the  bleeding  is  controlled. 
If  there  be  much  pain  and  distress  morphia  may  be  given  and  an 
ice  bag  applied  over  the  pubes  if  the  bladder  is  the  source  of  the 
bleeding.  The  source  of  the  bleeding  should  be  determined.  The 
treatment  of  each  of  the  various  affections  in  which  haematuria  may 
occur  as  a  symptom  will  be  considered  more  in  detail  in  their 
respective  chapters. 

By  means  of  the  cystoscope  or  urethroscope  it  should  not  be  dif&- 
cult  to  detect  the  source  of  bleeding. 

HEMORRHAGE  FROM  THE  URETHRA. 

Hemorrhages  from  the  urethra  are  produced  in  various  ways. 
The  causes  may  be  mechanical  or  from  pathological  conditions. 


122  MISCELLANEOUS   AFFECTIONS. 

The  mechanical  causes  are  from  the  introduction  of  an  over  sized 
bougie,  improper  or  forced  passage  of  any  instrument  and  by  calculi 
or  any  foreign  bodies  lodged  in  the  urethra;  severe  chordee  may 
also  give  rise  to  bleeding  from  the  urethra.  It  may  occur  from 
general  arterial  excitement.  The  pathological  conditions  causing 
hemorrhages  from  the  urethra  itself  are:  Erosion  of  a  blood-vessel 
in  chronic  ulcerations,  papilloma,  stricture. 

Treatment. — The  recumbent  posture,  application  of  cold  and 
pressure,  should  be  tried.  A  small  flat  piece  of  cork  should  be 
pressed  by  the  patient  against  the  perineum  and  gradually  brought 
forward  until  it  lights  on  the  point  of  bleeding  and  the  dripping  of 
blood  will  cease.  A  solution  of  adrenalin  chloride  i:iooo  may  be 
used  as  an  injection.  Gallic  or  tannic  acid  may  also  be  of  service. 
A  steel  bougie  first  put  in  very  hot  water  and  then  introduced  into 
the  urethra  is  often  used  to  arrest  this  variety  of  hemorrhage.  If 
the  hemorrhage  is  from  the  anterior  portion  of  the  urethra,  insert 
a  catheter,  and  apply  a  bandage  firmly  around  the  penis. 

FUNCTIONAL  DISORDERS— STERILITY. 

Either  by  reason  of  some  mechanical  defect  in  the  seminal  tract, 
or  some  alteration  in  the  semen  itself,  the  individual  is  devoid  of 
the  power  to  fecundate  the  ovum  of  the  female.  In  this  condition 
the  ability  to  copulate  and  the  powers  of  ejaculation  are  however 
preserved.     Impotence  and  sterility  may  coexist. 

Pederson  classifies  sterility  into  three  varieties: 

1.  Azoospermia  or  oligosperma — w^here  the  spermatozoa  are 
absent. 

2.  AsPERMiA — in  which  there  is  an  absence  of  seminal  fluid. 

3.  Malemission — or  improper  lodgment  of  the  ejaculated 
seminal  secretion  within  the  vagina  owing  to  some  deformity  of  the 
penis. 

Finger  recognizes  four  types  of  pathological  changes  in  the  semen 
which  may  cause  sterility;  viz.: 

I.  Azoospermia — defined  in  the  foregoing  paragraph  (q.v.). 


FUNCTIONAL   DISORDERS — STERILITY.  1 23 

2.  Oligozoospermia — or  diminution  of  spermatozoa. 

3.  Necrospermia — in  which  the  spermatozoa  are  motionless 
and  without  life. 

4.  Aspermia — absolute  and  temporary — classified  in  the  foregoing 
paragraph. 

Semen  normally  consists  of  the  secretions  of  the  seminal  vesicles, 
prostate,  Cowper's  glands,  Littre's  glands,  and  the  spermatozoa. 
Azoospermia  is  only  recognized  by  the  use  of  the  microscope.  This 
condition  exists  normally  before  the  age  of  puberty  but  in  adoles- 
cence is  due  to  pathological  changes,  e.g.,  frequent  nocturnal 
emissions  due  to  a  prolonged  habit  of  masturbation,  excessive  sexual 
indulgence  in  which  cases  the  absence  or  diminution  of  the  sperma- 
tozoa is  only  temporary  and  reappears  after  the  lapse  of  a  few  days 
from  intercourse.  Another  cause  is  the  X-rays,  among  workers 
engaged  in  this  work.  Most  of  these,  fortunately,  are  temporary, 
the  spermatozoa  reappearing  after  a  few  months'  absence  from 
exposure  to  the  X-rays. 

Considerable  attention  has  been  given  within  the  last  few  years  to 

the  OPERATIVE  TREATMENT  OF  STERILITY  IN  THE  MALE — due  tO  OCClu- 

sion  of  the  vas  deferens — either  traumatic  or  gonorrheal  in  origin, 
thus  obstructing  the  passage  of  semen  to  the  urethra  or  seminal 
vesicles. 

Thus  in  epididymitis  the  globus  minor  and  vas  deferens  become 
occluded,  and  because  there  is  here  but  one  efferent  duct,  while  in 
the  globus  major  the  efferent  ducts  are  numerous  and  obstruction  of 
one  or  two  would  still  leave  open  other  channels  that  the  operation  of 
anastomoses  of  the  vas  deferens  and  globus  major  was  considered 
and  successfully  performed  first  by  Martin,  and  later  Hagner  and 
others. 

Martin's  procedure  is  described  as  follows: 

An  incision  is  made  through  the  skin  and  covering  of  the  epi- 
didymis, which  is  approached  from  the  outer  side  so  as  not  to 
wound  the  spermatic  artery.  The  artery  of  the  vas  is  pushed  aside 
and  a  one-hal  f  inch  incision  is  made  in  the  vas  deferens  on  the  level 
with  the  globus  major,  along  its  axis,  care  being  taken  to  get  into 


124  MISCELLANEOUS   AFFECTIONS. 

the  lumen  of  the  tube.  A  portion  of  the  globus  major  is  picked  up 
between  two  fine  forceps  and  an  elliptical  piece  removed  to  corre- 
spond with  the  incision  in  the  vas  deferens.  An  examination  of  the 
fluid  obtained  by  squeezing  the  globus  major  will  show  spermatozoa. 
Four  fine  silver  wire  sutures  on  curved  intestinal  needles  are  inserted, 
one  at  the  upper  angle  of  the  wound  joining  the  vas  and  the  cut 
surface  of  the  epididymis,  one  at  the  lower  angle,  one  at  the  outer, 
and  one  at  the  inner  side.  When  these  are  drawn  out  a  perfect 
little  pocket  is  formed  by  the  spreading  out  of  the  cut  vas  deferens, 
and  the  elliptically  cut  globus  major.  The  wound  is  then  closed  and 
dressed. 

SPERMATORRHCEA. 

Strictly  defined,  the  term  spermatorrhoea  implies  a  condition  in 
which  there  is  a  discharge  of  material  containing  the  spermatozoa. 
(Fig.  I.)  This  often  occurs  in  individuals  of  the  neurasthenic  type, 
in  whom  there  is  a  history  of  masturbation  or  sexual  excess.  Con- 
scious of  their  vicious  habits  and  ignorant  of  the  physiology  of  the 
sexual  organs,  they  develop  hypochondriasis.  Their  chief  fear  is 
that  they  might  suffer  the  ''loss  of  manhood."  These  patients 
present  the  usual  constitutional  disturbances,  e.g.,  headache,  con- 
stipation, loss  of  appetite,  vague  muscular  pains,  and  general  debility. 
They  complain  chiefly  of  some  glary  mucoid  discharge  appearing 
at  the  meatus  after  defecation,  micturition,  or  an  erection,  which  is 
interpreted  as  semen.  Sometimes  the  habit  is  acquired  after  an 
attack  of  urethritis,  of  passing  the  urine  into  a  glass  vessel  and 
examining  it.  Their  suspicion  is  aroused  at  the  least  presence  of 
mucus,  pus,  threads,  etc.,  as  being  seminal  material.  Spermator- 
rhoea is  easily  confounded  with  prostatorrhoea.  Repeated  micro- 
scopic examination  of  the  urine  is  imperative  before  an  accurate 
diagnosis  of  spermatorrhoea  can  be  made. 

The  causes  are  practically  the  same  as  those  of  impotence  (q.v.). 

Treatment  consists  of  sedatives,  tonics,  rest,  and  general  hygienic 
measures,  abstinence  from  the  use  of  alcohol  and  tobacco.  Elec- 
tricity and  massage  should  also  be  tried. 


HEMATOSPERMIA.  1 25 

NOCTURNAL  EMISSIONS. 

Involuntary  emissions  of  seminal  material  during  sleep,  accom- 
panied by  a  lascivious  dream,  frequently  occur  in  vigorous  adults. 
These  emissions  are  attended  with  an  erection  and  the  ecstasy  of 
sexual  excitement.  Sometimes  the  patient  may  have  the  emissions 
altogether  unconsciously,  without  the  least  recollection  on  awaken- 
ing. When  they  occur  no  oftener  than  once  in  ten  days  it  is  said 
to  be  harmless  to  the  health  of  the  individual.  The  cases  of  noc- 
turnal emissions  are  most  often  met  with  in  patients  of  the  anaemic 
and  neurotic  type  where  there  is  more  or  less  nervous  exhaustion 
from  one  cause  or  other. 

Treatment. — The  patient  should  be  assured  that  the  condition 
is  nothing  abnormal  and  the  physiology  of  the  parts  briefly  explained. 
The  treatment  for  impotence  (q.v.)  applies  with  equal  force  to 
nocturnal  emissions. 

HEMATOSPERMIA. 

Hematospermia — or  as  it  is  often  called,  Hemospermia,  or  blood 
in  the  seminal  discharge  occurs  frequently  during  the  course  of  an 
acute  inflammatory  condition  involving  the  posterior  urethra,  or 
adnexa.  The  present  belief  is  that  when  the  seminal  discharge 
occurring  during  the  course  of  an  acute  urethritis  is  blood-stained, 
the  site  of  the  bleeding  is  usually  the  prostatic  urethra  or  the  veru- 
montanum.  The  blood  may  come  directly  from  the  vesicles  as  a 
symptom  of  a  severe  acute  vesiculitis. 

Ulzmann  differentiates  the  source  of  the  bleeding  by  assuming 
that  when  the  blood  comes  from  the  prostate,  or  prostatic  urethra, 
the  dried  stains  on  the  linen  appear  irregularly  colored,  while  in 
bleeding  from  the  vesicle,  the  stains  appear  evenly  colored,  showing 
an  intimate  mixing  of  the  blood  with  the  semen. 

Tuberculosis,  syphilis,  and  malignancy  may  be  possible  etiologic 
factors  in  obscure  cases  of  vesicular  hemorrhage. 

Hematospermia  occurring  in  the  absence  of  disease  of  the  seminal 
vesicles  may  result  from  congestion  of  the  utricular  wall. 


126  MISCELLANEOUS   AFFECTIONS. 

SEXUAL  IMPOTENCE. 

Broadly  speaking,  impotence  may  be  said  to  be  a  condition  in 
which  there  is  a  partial  or  complete  inability  to  perform  the  sexual 
act.  For  clinical  consideration  and  the  convenience  of  description, 
Gross  classified  it  into  four  types:  (a)  atonic,  (b)  psychical,  (c) 

SYMPTOMATIC,  (d)  ORGANIC. 

A  tonic  inipotence  is  by  far  the  most  common  variety  and  is 
defined  as  a  form  in  which  there  is  a  loss  of  the  power  of  erection 
to  a  greater  or  less  degree,  without  deficiency  in  ejaculation.  In 
fact  the  ejaculatory  function  is  increased.  Sexual  desire  is  present 
but  usually  the  erection  lasts  but  for  a  moment,  and  is  attended  with 
a  premature  ejaculation. 

Causes. — Subacute  and  chronic  inflammation  of  the  deep 
urethra,  hyperesthaesia  of  the  urethra,  prolonged  and  excessive 
masturbation,  and  excessive  sexual  indulgence. 

Symptoms. — In  addition  to  the  sexual  weakness  complained  of 
by  the  patient,  he  will  present  a  history  of  frequent  nocturnal 
emissions,  insomnia,  or  restlessness,  anorexia,  headache,  vertigo, 
malaise,  evidence  of  neurasthenia,  melancholy,  and  some  mental 
aberrations  may  also  be  noted. 

Diagnosis. — Examination  of  the  urethra  with  the  bougie  will 
reveal  its  hyperaesthetic  condition.  With  the  endoscope  may  be 
seen  the  hyperaemic  condition  of  the  mucous  membrane.  Exami- 
nation of  the  prostate  and  vesicles  by  the  rectum  will  disclose  ten- 
derness and  abnormalities  of  the  prostate  from  chronic  inflammation. 

Prognosis. — In  the  youthful  and  robust  where  the  causative 
factor  has  been  ascertained  it  is  favorable.  When  the  etiology  is 
obsure  and  the  patient  debilitated  and  neurasthenic,  it  is  extremely 
difficult  to  obtain  favorable  results. 

Treatment. — The  treatment  should  resolve  itself  into  local  and 
constitutional  measures.  Guided  by  the  causative  factor  and  the 
physical  condition  of  the  patient,  the  treatment  is  governed  accord- 
ingly. The  cause  must  be  ascertained  by  careful  digital  examina- 
tion per  rectum  of  the  prostate  and  seminal  vesicles.     The  penis. 


SEXUAL    IMPOTENCE. 


127 


urethra,  and  bladder  should  also  be  examined.  Any  abnormalities 
thus  found  must  be  treated.  Pathological  changes  in  any  of  these 
structures  may  be  the  direct  or  indirect  cause  of  impotence,  there- 
fore any  hyperaemic  or  hyperaesthetic  condition  of  the  mucous 
membrane  should  be  carefully  noted. 
The  best  agents  to  overcome  the  hype- 
raemia  and  hyperaesthesia  are:  the  cold 
sound  (Beneque  curve)  or  still  better 
the  psychrophore  (Fig.  36)  and  in- 
stillations of  silver  nitrate  2  to  5  grs.  to 
the  oz.  The  passage  of  a  cold  sound 
should  be  performed  every  third  or 
fourth  day,  allowing  it  to  remain  in  the 
urethralonger  at  each  seance.  As  the 
hypersensitiveness  is  slowly  reduced 
the  size  of  the  calibre  may  be  gradu- 
ally increased.  If  upon  endoscopic 
examination,  lesions,  e.g.,  granular  or 
congested  patches  and  erosions  are 
found  in  the  urethra,  applications  of 
silver  nitrate  solution  (10  to  15  grs. 
to  the  oz.)  made  directly  thereto  are 
of  great  service.  The  prostate  should 
also  be  massaged  once  each  week. 
This  improves  its  muscular  tone  and 
often  stimulates  erection  and  the  ejacu- 
lations become  less  premature. 

Constitutional  Treatment. — ^First, 
an  attempt  must  be  made  to  make  a 
deep  impression  on  the  patient  as  to 
the  prognosis  and  the  importance  of 
his  co-operation.     All  forms  of  sexual 

excitement  should  be  prohibited.  This  is  imperative.  He  should 
avoid  the  company  of  women,  and  if  married,  he  should  sleep  in 
another  room.     His  mind  must  be  kept  occupied  and  exercise,  e.g., 


Fig.  36. — Psychrophore. 


125  MISCELLANEOUS   AFFECTIONS. 

walking,  swimming  to  a  moderate  amount.  The  personal  hygiene 
of  the  patient  must  likewise  not  be  overlooked.  As  much  life  in  the 
open  air  as  possible  is  highly  beneficial.  Change  of  climate,  frequent 
warm  baths  followed  by  a  cold  shower  and  brisk  rubbing  with  a 
Turkish  towel  are  also  advised.  He  should  have  at  least  eight 
hours  sleep  daily  and  on  a  hard  mattress,  without  too  much  cover. 
The  diet  should  be  wholesome  and  nutritious,  and  the  use  of  alcohol 
and  tobacco  strongly  interdicted,  unless  he  be  an  habitue  in  which 
instance  the  amount  must  be  reduced  to  a  minimum.  Attention  to 
the  bowels  is  essential  and  care  taken  to  avoid  constipation.  Inter- 
nally some  nervous  sedative,  e.g.,  sodium  or  potassium  bromide 
should  be  given. 

The  following  formula    is  often  of  service: 

1^      Tr.  belladonna n^  xxx 

Liq.  potassa 5  iv 

Sodii  bromide O  iv 

Syr.  zingiberus 5  ij 

Aquae  q.s.  ad B  vi 

Sig. — Tablespoonful  t.  i.  d. 

The  bromides  may  also  be  combined  with  quinine,  with  which 
its  therapeutic  efficacy  is  said  to  be  increased.  When  the  urethra 
mucous  membrane  is  restored  to  its  normal  integrity  and  the 
impotence  still  persists,  the  genital  centres  in  the  brain  and  cord  may 
remain  in  their  exhausted  condition. 

For  this  purpose  Pederson  recommends: 

I^     Quinine  sulph. .  .  .  .• 

Ferri  sulph aa  9  ij 

Zinci  phosphidi grs.  ij 

I^     Strych.  sulph gr.  2  /  3 

Fiat  pil xl 

Sig. — Two  t.  i.  d. 

Electricity  in  the  form  of  a  galvanic  current  is  also  often  of  service 
especially  when  the  symptoms  are  those  of  a  depressed  spinal  or 


PSYCHICAL    IMPOTENCE.  1 29 

cerebral  centre.  The  positive  pole  (anode)  placed  over  the  lumbar 
spine  and  the  negative  electrode  (cathode)  over  the  perineum  and 
genitals.  The  current  should  be  mild  and  continuous,  lasting  from 
3  to  5  minutes  and  given  every  two  or  three  days.  Faradic  current 
may  also  be  used. 

PSYCHICAL  IMPOTENCE. 

Synonyms.  Imaginary  and  False  Impotence. — This  form  of 
impotence  is  manifested  by  absent  or  incomplete  erection  with  pre- 
mature ejaculation  and  differs  principally  in  its  origin  and  is  not  so 
serious  as  the  atonic  variety.  Psychical  impotence  results  from 
some  emotional  disturbance,  e.g.,  embarrassment  or  fear,  or  excite- 
ment attending  the  first  coitus  of  a  virtuous  and  newly  married  man. 
Other  emotional  factors  are  extreme  joy,  grief,  fright,  disgust,  and 
suspicion.  Neurasthenics,  by  reason  of  the  slightest  abnormality 
of  the  genitals,  are  apt  to  become  impotent.  Apprehension  over 
youthful  excesses  or  masturbation  are  also  contributing  causes  of 
this  condition. 

Diagnosis. — A  careful  history  and  examination  of  the  patient, 
including  a  careful  exploration  of  the  urethra,  must  always  be  made 
so  as  to  exclude  the  presence  of  lesions,  which  if  found  must  be 
treated  locally. 

Prognosis. — Usually  favorable  where  the  condition  is  truly 
psychical. 

Treatment. — In  this  class  of  patients,  positive  assurance  of  the 
safety  and  nature  of  the  sexual  act,  its  hygiene,  etc.,  is  often  all  that 
is  required.  Where  the  patient  presents  evidences  of  hypochondri- 
asis the  treatment  is  more  difficult.  Temporary  absence  of  coitus 
must  be  insisted  upon.  The  other  measures  are  practically  the 
same  as  that  given  for  atonic  impotence,  until  a  mental  effect  is 
obtained.     Then  assurances  are  in  order. 

SYMPTOMATIC  IMPOTENCE. 

This  variety  is  often  due  to  the  prolonged  use  of  drugs,  also  from 
9 


130  MISCELLANEOUS   AFFECTIONS. 

lesions  of  the  cerebral  or  spinal  centres  and  in  some  forms  of  an 
acute  or  chronic  exhaustive  disease.  The  drugs  which  may  pro- 
duce a  condition  of  impotence  are  alcohol,  tobacco,  opium  or  its 
alkaloids,  chloral,  bromides,  arsenic,  antimony,  and  lead. 

The  acute  diseases,  sometimes  constituting  the  etiology  of  this 
affection  are,  phthisis,  diabetes,  and  Bright' s  disease. 

Prognosis. — When  due  to  central  nerve  lesions,  it  is  unfavorable, 
otherwise  good  when  the  cause  is  removed. 

Treatment. — Should  consist  of  .vigorous  tonics,  hygienic  living, 
withdrawal  of  the  drug  (if  impotence  is  thus  produced)  and 
electricity. 

ORGANIC  IMPOTENCE. 

The  inabiUty  to  copulate,  due  to  some  physical  abnormality, 
whether  congenital  or  acquired,  constitutes  the  organic  type. 
Elephantiasis  of  the  penis,  hypospadias,  epispadias,  tumors,  varicose 
of  the  dorsal  vein,  etc.,  represent  the  most  common  of  the  causes. 
Certain  lesions  of  the  testicle  resulting  in  sterility  may  secondarily 
give  rise  to  impotence. 


CHAPTER  VI. 

DISEASES  OF  THE  SEMINAL  VESICLES. 

Anatomy  of  the  Seminal  Vesicles. — These  are  situated  one  on 
either  side  between  the  base  of  the  bladder  and  the  rectum,  just 
under  the  recto-vesicle  fold  junction,  and  serve  as  reservoirs  for  the 
fluid  secreted  by  the  testes  and  also  secrete  a  fluid  accessory  to  that 
of  the  testicles.  They  are  imperfectly  developed  until  after  the  age 
of  puberty.     Each  vesicle  is  a  tube  but  so  convoluted  that  it  is  like 


FiG.   37. — Posterior    view   of   the   bladder,      i.   Ureter.      2.   Vas   deferens.    3.  Seminal 
vesicle.      4.   Trigone.      5.   Prostate.      (After  Holden.) 

a  litde  sacculated  bladder.  Both  vesicles  diverge  from  the  other — 
posteriorly  as  far  as  the  reflecting  af  the  rectovesical  peritoneal 
pouch — like  the  branches  of  the  letter  V  and  each  lies  on  the  outer 
side  of  the  vas  deferens  into  which  it  opens.  The  ureter  dips  into 
the  bladder  just  anterior  to  the  vas  (see  Fig.  37). 

Acute  Seminal  Vesiculitis. — The  seminal  vesicles  frequently 
become  involved  secondarily  by  extension  through  the  ejaculatory 
ducts  from  a  posterior  urethritis,  or  its  implication  may  be  due  to  a 

131 


132  DISEASES    OF    THE    SEMINAL   VESICLES. 

gonorrhoeal  prostatitis.  The  anatomical  relationship  of  the  seminal 
vesicle  to  these  structures  is  shown  in  the  accompanying  illustration. 

Symptoms. — The  symptoms  are  always  more  or  less  obscure  but 
present  mostly  those  of  a  posterior  urethritis.  In  addition  there  is 
a  throbbing  pain,  deep  seated  in  the  rectum,  and  tenderness  in  the 
suprapubic  region.  If  the  involvement  is  confined  to  the  seminal 
vesicles,  and  the  infection  in  the  posterior  urethra  has  been  erad- 
icated, the  urine  at  first  is  clear,  but  later,  when  the  vesicles  begin 
to  empty  themselves  into  the  prostatic  urethra,  the  contents  of  the 
bladder  become  contaminated  and  the  effete  material  is  found  in  the 
urine.  Sometimes  the  discharge  from  the  vesicles  is  dark  brown  or 
red  in  color  from  the  admixture  with  blood,  which  may  be  either 
from  the  seminal  vesicle  itself  or  from  the  posterior  urethra.  The 
source  must  be  definitely  ascertained. 

Diagnosis. — This  can  only  be  made  by  a  digital  examination  via 
the  rectum.  The  vesicles  will  be  found  swollen,  soft  and  boggy, 
sometimes  fluctuating,  and  extremely  tender  in  the  acute  stage 

Complications. — Principally  epididymitis,  and  though  rarely 
peritonitis.  Epididymitis  occurs  as  the  result  of  some  of  the  gon- 
ococci  finding  their  way  through  the  vas  deferens  into  the  epididy- 
mis. Peritonitis  is  the  result  of  the  close  anatomical  relation  which 
the  perineum  bears  to  the  vesicles. 

Treatment. — Patient  should  be  given  absolute  rest  by  being  put 
to  bed  and  given  a  saline  cathartic.  Hot  sitz  baths  and  copious 
irrigation  per  rectum  with  hot  or  ice  water  affords  relief  by  allaying 
the  inflammation.  If  the  symptoms  of  posterior  urethritis  are 
present,  oil  of  sandalwood  and  a  1/2  gr.  opium  suppository  are 
useful  in  relieving  the  tenesmus  and  in  rendering  the  urine  bland. 

Chronic  Seminal  Vesiculitis. — When  the  acute  conditions  do 
not  yield  to  treatment  as  outlined  above,  the  condition  becomes 
chronic.  Chronic  seminal  vesiculitis  has  been  classified  by  Fuller 
in  two  varieties,  (i)  atonic  vesiculitis,  in  which  the  muscular  fibres 
of  the  walls  of  the  vesicle  become  atonic,  (2)  inflammatory  vesiculitis, 
in  which  the  walls  become  thickened  and  indurated,  either  from, 
simple  gonorrhoea  or  tubercular  origin. 


VASOTOMY. 


133 


Vasotomy  devised  by  Belfield  consists  of  draining  and  medicating 
vas,  ampulla,  and  vesicle  through  an  incision  into  the  vas;  and 
extending  the  incision  into  the  epididymis  when  necessary — 
(epididymo-vasotomy) .     It  can  be  done  in  the  office  under  cocain 


Fig.  38. — Shows  the  prostate;  the  seminal  vesicles,  with  the  vasa  ampulae  partially 
dissected  away.  Shows  the  ejaculatory  ducts  running  into  the  prostatic  fissure: 
This  is  the  normal  relation  of  the  vesicles  to  the  prostate.  Both  the  vesicles  in  this 
case  are  pathologic.      Note  the  minuteness  of  the  ejaculatory  ducts.      (Barnett.) 


anaesthesia,   often  without  assistance,   sometimes  passing    a    wire 
through  the  vas  and  ejaculatory  duct  to  the  urethra. 

By  this  trivial  operation,  the  entire  seminal  duct  is  relieved  of 
abnormal  tension,  vas  and  vesicle  are  drained  and  medicated,  the 


134  DISEASES    OF    THE    SEMINAL    VESICLES. 

epididymis  is  protected  from  infection  or,  if  already  infected,  from 
pressure  infection;  it  has  sometimes  seemed  that  the  pus  drained 
from  the  epididymis  also.  Medication  of  the  vesicle  is  effective, 
because  the  injected  solution  remains  in  its  cavity  for  hou'rs  or  days. 
When  prelimina'ry  cleansing  is  desired,  a  slow  stream  can  be  injected 
through  the  vas  to  the  vesicle  and  milked  into  the  urethra  by  the 
finger  in  the  rectum  (demonstrated  with  argyrol  solution.) 

Technic,  as  described  by  Belfield,  consists  of  (i)  fixation  of  the 
vas,  which  otherwise  may  drop  into  the  scrotum  and  be  recaptured 
with  difficulty;  (2)  pulling  of  vas  through  the  skin-cut  above  the 
skin,  for  manipulation.  Details  may  obviously  be  varied  at  the 
discretion  of  the  operator;  the  following  is  one  of  several  useful 
methods:  After  the  usual  cleansing  and  cocainizing,  the  cord  is 
caught  by  a  vulsellum  forceps  whose  points  do  not  quite  meet  and 
hence  do  not  pierce  the  subscrotal  structures;  the  cord  is  caught 
an  inch  lower  by  a  second  vulsellum.  If  necessary  to  secure  space, 
the  contracted  dartos  can  be  relaxed  by  a  hot  fomentation.  The 
cord  between  the  vulsella  is  supported  by  the  left  fore-finger  while 
a  1/2-inch  cut  is  made  down  to  the  sheath  of  the  vas.  This  is 
carefully  opened,  the  vas  pulled  out,  and  its  canal  opened  longitudi- 
nally; a  thread  or  wire  may  be  passed  into  the  vas  for  exploration 
if  desired.  A  canaliculus  or  other  blunt  needle  attached  to  a 
small  syringe  is  introduced  into  the  vas  and  the  solution  sIo-aIv 
injected;  2  or  3  drachms  often  distend  the  vesicle  uncomfortably. 
The  finger  in  the  rectum  can  press  some  of  the  vesicular  contents 
into  the  urethra,  permitting  the  injection  of  more  solution  into  the 
vas.  A  catgut  or  other  thread,  passed  into  the  lumen  of  the  vas 
upward  for  a  quarter-inch  and  then  out  through  its  wall  and  tied 
loosely  above  the  skin,  serves,  if  subsequent  injections  are  necessary, 
to  keep  the  vas  open,  to  pull  the  vas  out  of  the  skin-cut,  and  to 
guide  the  needle  into  its  lumen.  If  complete  transverse  division 
of  the  vas  be  deemed  necessary,  the  silk-worm  or  catgut  thread 
is  passed  into  the  lumen  and  out  through  the  wall  of  each  cut  end, 
and  the  thread  ends  tied  loosely  above  the  skin.  When  reunion 
of  the  cut  ends  is  desired,  this  thread  loop  is  tightened,  the  thread 


ATONIC    VESICULITIS.  I35 

serving  as  an  axis  splint  which  secures  exact  apposition  of  the  cut 
ends  of  the  vas.  This  principle,  first  published  by  Mayo  (Annals 
of  Surgery,  Jan.,  1895,  which  publication  has  been  ignored  by 
certain  later  writers),  supersedes  all  other  methods  of  reuniting 
the  divided  vas.  Incidentally  Belfield  discovered  that  a  vas  of 
which  a  half-inch  has  been  resected,  can  spontaneously  reunite 
with  a  patulous  lumen ;  evidently  because  the  two  ends  are  kept  in 
the  same  axis  by  the  sheath  of  the  vas  and  are  brought  together  by 
the  shortening  of  the  scrotum  through  the  contractions  of  the  dartos, 
which  usually  follow  a  wound  of  the  scrotum.  This  is  important 
to  remember  in  performing  vasectomy. 

The  vas  can  be  opened  through  either  anterior  or  posterior  wall 
of  the  scrotum;  though  each  has  its  advantages,  the  latter  seems 
preferable,  the  patient  lying  in  the  semi-prone  position. 

The  advantages  of  this  procedure  over  medical  treatment  are: 
(i)  shortening  the  time  of  pain,  fever,  swelling,  and  confinement;  the 
patient  is  ready  to  resume  ordinary  avocations  in  two  to  four  days; 
(2)  avoidance  of  the  usual  chronic,  tender  induration  in  tke  tail  of 
the  epididymis,  which  sometimes  contains  pus  and  gives  rise  to 
recurrent  epididymitis.  Whether  the  chance  of  permanent  occlu- 
sion of  the  epididymal  canal  is  increased  or  diminished  by  the 
incision  remains  for  larger  experience  to  determine. 

Atonic  vesiculitis  is  induced  by  non-resolution  of  an  acute 
inflammation  in  the  organ.  It  is  in  most  cases  caused  by  sexual 
excesses  and  the  consequence  of  which  the  atonic  condition  of  the 
muscular  fibres  is  occasioned.  By  reason  of  the  loss  of  tone  the 
walls  of  the  cavities  become  distended  and  the  muscular  fibres  are 
unable  to  evacuate  their  secretion.  The  expression  urine  which  is 
obtained  by  allowing  the  patient  to  urinate  in  one  glass  and  then 
stripping  the  vesicles  vigorously  and  allowing  him  to  empty  the  re- 
maining contents  in  a  second  glass  which  will  contain  the  expressed 
seminal  fluid.  This  appears  in  masses  of  gelatinous  material  about 
1/2  in.  long,  and  about  as  thick  as  a  straw.  In  addition  to  this 
flakes  of  inspissated  semen  are  also  found.  Very  often  the  vesicle 
thus  affected  becomes  the  seat  of  invasion  from  the  bacillus  coli  of 


136  DISEASES    OF    THE    SEMINAL   VESICLES. 

the  rectum,  giving  rise  to  chronic  inflammation  with  or  without 
perivesiculitis. 

Even  where  there  are  hyperplastic  changes  in  the  connective 
tissues  surrounding  the  vesicles,  the  ejaculatory  duct  is  not  com- 
pressed and  its  function  not  impaired  with,  therefore,  sterility  does 
not  result. 

Etiology. — Principal  cause  is  gonorrhoeal  infection  but  it  may 
originate  from  sexual  abuse  and  traumatism,  also  in  individuals 
who  are  being  catheterized  and  from  chronic  inflammatory  changes, 
adjacent  to  the  vesicles. 

The  symptoms  depend  upon  whether  the  posterior  urethral 
infection  coexists,  in  which  case,  tenesmus  and  frequent  micturition 
are  present.  On  straining  in  the  act  of  defecation  a  viscid  glary 
discharge  seen  at  the  meatus  will  be  noticed  which  is  sometimes 
called  prostatorrhoea.  The  mental  symptoms  are  depression,  irrita- 
bility, hypochondria,  and  tendency  to  melancholia.  The  sexual 
function  is  more  or  less  impaired.  There  are  frequent  nocturnal 
emissions  and  premature  ejaculations  which  are  often  clotted  with 
blood,  and  sooner  or  later  impotence  is  established. 

Diagnosis. — The  history  will  usually  include  some  gonorrhoeal 
infection,  which  the  patient  complains  has  never  been  entirely 
cured.  The  discharge  from  the  meatus  appears  in  exacerbated 
form  on  the  least  indiscretion.  In  the  course  of  a  few  days  this  may 
subside  only  to  appear  again  on  the  next  indiscretion.  The  exami- 
nation of  the  vesicles  per  rectum  will  reveal  the  true  condition  of 
affairs  to  one  who  is  familiar  with  the  normal  touch  of  these  parts.- 
In  making  an  examination,  the  bladder  should  be  moderately  dis- 
tended with  urine  and  the  patient  placed  in  the  knee-chest  position. 
The  normal  vesicles  will  feel  soft  and  attended  with  little  or  no 
pain  to  the  touch,  whereas,  in  the  atonic  variety  they  are  swollen, 
tense,  and  very  sensitive.  Sometimes,  especially  where  perivesicu- 
litis exists,  they  are  hard  and  indurated. 

Treatment. — This  should  comprise  massage  of  the  vesicles  every 
four  or  five  days,  or  even  once  a  week.  The  effects  of  the  massage 
in  emptying  the  vesicles  of   their  inspissated  material  gives   the 


TUBERCULOUS    VESICULITIS.  137 

muscular  fibres  of  the  walls  a  chance  to  regain  their  normal  tonicity. 
The  contraindications  of  stripping  of  the  vesicles  are  the  existence 
of  an  acute  attack,  blood  in  the  seminal  secretion,  or  extreme  sensi- 
tiveness. There  is  always  more  or  less  danger  of  epididymitis 
when  these  conditions  are  present.  Infection  of  posterior  urethra 
must  be  treated  by  instillation  with  Keyes,  Ultzmann,  or  Guyon 
syringe.  This  local  treatment  of  the  urethra  and  the  stripping  of 
the  vesicles  should  alternate  one  another  and  never  be  done  at  the 
same  seance. 

The  duration  of  treatment  is  usually  from  a  couple  of  months 
to  a  year. 

Tuberculous  Vesiculitis. — This  lesion  occurs  secondarily  to  a 
tubercular  foci  somewhere  in  the  genito-urinary  tract,  and  results 
in  consequence  of  an  extension,  as  for  instance,  from  the  epididymis 
by  way  of  the  vas  deferens.  Gonorrhoeal  infection  is  a  frequent 
predisposing  element.  The  vesicles  are  nodular  and  progress 
slowly,  but  with  a  tendency  to  invade  adjacent  tissues.  Sometimes 
with  the  formation  of  a  perivesicular  abscess,  which  results  often  in 
a  fistulous  opening  in  the  rectum  or  perineum. 

The  Diagnosis. — This  is  based  largely  on  the  nodular  character 
of  the  gland  and  its  surrounding  tissues.  In  these  conditions  the 
prostate  is  also  involved. 

Treatment. — This  consists  in  hygienic  measures  such  as  out- 
door life  and  abundant  nutritious  diet,  suitable  climate,  internally 
cod-liver  oil  and  creosote  are  indicated.  Radical  treatment,  e.g., 
extirpation,  is  not  satisfactory.  Should  there  be  abscess  formation 
it  may  be  drained  through  a  free  incision  in  the  perineum. 


CHAPTER  Vn. 

AFFECTIONS  OF  THE  TESTIS  AND  ITS 
APPENDAGES  AND  COVERINGS. 

The  scrotum  is  a  pouch  of  skin  in  which  the  two  testicles  are 
normally  lodged.  It  consists  of  two  layers,  integument  and  dartos, 
respectively.  In  the  middle  of  the  scrotum  is  the  raph^  and  dividing 
the  pouch  there  is  a  septum.  The  coverings  of  the  testes,  in  addition 
to  the  integument  and  dartos,  are  the  inter columhar  or  spermatic 
fascia^  derived  from  the  pillars  of  the  external  abdominal  ring. 
The  cremasteric,  coming  from  the  internal  oblique  muscle,  the  infun- 
dibuliform  fascia,  and  the  tunica  vaginalis,  derived  from  the  parietal 
layer  of  the  peritoneum. 

The  testis  is  oval  shape  and  is  suspended  obliquely  in  the  scrotum 
by  the  spermatic  cord.  The  left  is  usually  lower  than  the  right. 
On  the  posterior  surface  is  the  appendage  known  as  the  epididymis, 
which  is  a  continuation  of  the  convolution  in  the  testicle.  The 
upper  or  larger  end  is  termed  the  globus  major,  wMe  the  lower  or 
smaller  end  is  referred  to  as  the  globus  minor,  the  two  being  con- 
nected by  the  body.  Intimately  surrounding  the  testicles  are  two 
other  coverings,  known  as  the  tunica  albiiginea  and  tunica  vasculosa. 

Histologically  the  testicle  presents  numerous  lobules;  each  con- 
tain two  or  more  seminiferous  tubules,  which  if  unraveled  would 
measure  i8  inches  in  length  (Fig.  38).  The  testes  receive  their 
blood  supply  from  the  deep  epigastric,  superficial  and  deep  external 
pudic  and  the  internal  pudic. 

The  vas  deferens  begins  at  the  lower  end  of  the  globus  minor 
of  which  it  is  a  continuation.  After  passing  along  with  the  cord, 
through  the  inguinal  canal  it  enters  the  abdomen  through  the  inter- 
nal ring  where  it  curves  around  the  side  and  lower  part  of  the  blad- 
der and  joins  the  ejaculatory  duct,  which  empties  itself  into  the 
prostatic  urethra,  running  a  course  of  about  2  feet. 

f38 


AFFECTIONS    OF    THE    SCROTUM. 


139 


AFFECTIONS  OF  THE  SCROTUM. 

The  scrotum  may  be  the  seat  of  wounds  and  contusions,  the 
various  dermatoses  presenting  no  special  symptoms  nor  requiring 
any  particular  treatment,  other  than  when  seen  in  other  parts. 

The  other  principal  affections  of  the  scrotum  are:  oedema, 
emphysema,  sebaceous  tumors,  gangrene,  and  elephantiasis.  (See 
Fig.  39.)  CEdema  of  the  scrotum  is  often  associated  with  renal  and 
cardiac  affections  and  after  a  complete  extirpation  of  inguinal  glands. 


Fig.   38. — Diagram  of  a  vertical  section  through  the  testicle. 
2.  Trabeculse.     3.   One    of    the    lobules.     4-4.   Vasa    recta. 


I.   Mediastinum  testis. 
5.   Globus    major.     6. 


Globus  minor  of  the  epididymis. 


Vas  deferens.      (After  H olden.) 


Emphysema  is  frequently  found  in  cases  of  urinary  extravasation 
into  the  scrotal  tissues.  Gangrene  sometimes  occurs  as  a  result  of 
injury  or  extravasation  of  urine.  It  may  also  occur  spontaneously 
without  a  definite  cause,  in  individuals  of  the  alcoholic  habit  and  in 
debilitated  subjects  suffering  with  diabetes  and  Bright' s  disease. 
Tumors  of  the  scrotum  most  often  met  with  are:  sebaceous  cysts, 
lipoma,  sarcoma,  and  epithelioma.  The  latter  malignant  growths 
usually  arise  secondarily  to  growths  in  adjacent  structures. 

Gangrene  of  the  Scrotum. — May  be  due  to  bacteria,  to  inter- 
ference with  the  circulation,  to  heat  or  cold,  and  to  injury  of  the 
trophic  nerves.     The  symptoms  vary  according  to  the  cause.     The 


I40 


AFFECTIONS    OF   THE    TESTIS. 


PROGNOSIS  should  be  guarded,  as  the  mortahty  is  25  per  cent.  The 
testicles  almost  invariably  retain  their  functions  if  the  patient 
recovers.  The  most  effective  treatment  is  prophylactic.  Inter- 
ference with  free  flow  of  the  urine 
must  be  corrected,  wounds  asep- 
ticized, scrotal  swellings  incised, 
except  when  due  to  non-inflamma- 
tory oedema,  in  which  case  the 
underlying  cause  must  be  treated. 
Gangrenous  tissue  should  be  re- 
moved with  strict  antisepsis,  paying 
special  attention  to  recesses  in 
which  pus  might  collect.  The 
testicles  will  be  covered  by  granu- 
lation tissue  which  will  form  a  suffi- 
ciently useful  scrotum,  or  a  larger 
one  may  be  formed  by  a  plastic 
operation.  Castration  should  never 
be  done  unless  the  testicles  are 
gangrenous.  Even  when  this  is 
suspected  it  is  better  to  wait  until 
nature  throws  off  the  sloughing  por- 
tions before  sacrificing  the  entire 
testicle. 

.  Hydrocele  consists  of  a  serous 
effusion  into  the  cavity  of  the  tunica 
vaginalis.  (Fig.  40.)  It  may  also 
occur  in  cysts  of  the  testes  and  ep- 
ididymitis in  the  spermatic  cord  in  which  instance  it  is  termed 
encysted  hydrocele. 

Varieties. — Hydrocele  of  the  tunica  vaginalis  and  hydro- 
cele OF  the  cord.  Either  condition  may  be  congenital  or  acquired. 
Congenital  hydrocele  occurs  where  there  has  been  improper 
foetal  development  in  which  there  is  a  communication  of  the  tunica 
vaginalis  testis  with  the  peritoneal  cavity  owing  to  the  failure  in 


Fig.   39. 
turn. 


—Elephantiasis   of  the  scro- 
(Native  of  Fiji  Islands.)  ■ 


AFFECTIONS    OF    THE    SCROTUM. 


141 


the  obliteration  of  the  opening.  After  the  descent  of  the  testicle 
from  the  abdominal  cavity  into  the  scrotum,  owing  to  this  defect 
there  is  an  accumulation  of  serous  fluid  in  the  cavity  of  the  tunica 
vaginalis,  which  distends  the  sac,  this  being  much  more  noticeable 
when  the  patient  is  standing  and  walking. 

Diagnosis. — The  scrotal  tumor  is  seen  in  early  life,  will  be  found 
smooth,  translucent,  fluctuating,  and  trans- 
parent and  extends  well  toward  the  inguinal 
canal.     It  is  dull  on  percussion  in  contra- 
distinction to  the  resonance  of  hernia. 

Treatment. — Pressure  by  means  of  a 
well  fitting  and  firmly  applied  truss  from 
the  inguinal  canal  will  usually  effect  a 
closure  and  soon  be  followed  by  absorption 
of  the  effusion  in  the  tunica  of  the  vaginalis. 
If  pressure  fails  to  obliterate  the  f uniculif orm 
or  vaginal  process,  the  sac  may  be  aspirated 
by  multiple  needle  punctures,  and  the  pres- 
sure reapplied.  If  there  be  a  coexisting 
hernia  a  radical  operation  will  cure  both 
conditions;  and  therefore  should  be  advised. 

Acquired  Hydrocele  of  the  Tunica 
Vaginalis  Testes. — This  variety  of  hydro- 
cele is  most  frequently  seen  in  adults  and  is 
usually  unilateral,  rarely  both  sides  invol- 
ved. The  tumor  is  as  a  rule  egg  shaped,  with  its  base  at  the 
bottom  of  the  scrotum,  its  long  axis  directed  toward  the  abdominal 
ring;  it  varies  in  size  according  to  the  amount  of  effusion.  The 
scrotal  tissues  are  more  or  less  distended  and  upon  palpation  will 
be  felt  a  firm  elastic  tumor  and  fluctuation.  Hydrocele  is  not  at- 
tended with  any  pain,  except  at  the  seat  of  the  testicle. 

Its  onset  is  gradual  and  its  progress  insidious,  often  not  being 
noticed  by  the  patient  until  it  assumes  some  proportions.  The 
contained  fluid  is  highly  albuminous,  usually  clear  and  straw 
colored,  it  may  however  contain  blood,  thus  altering  the  color. 


Fig.  40. — Transverse  sec- 
tion through  the  left  testi- 
cle. (The  dots-^show  the 
reflections  of  the  tunica 
vaginalis.)  i.  Spermatic 
artery.  2.  Vas  deferens. 
3.  Deferential  artery.  4. 
Epididymis.  5.  Mediasti- 
num testis;  6-6.  Cavitj'  of 
the  tunica  vaginalis.  {After 
Holden.) 


142 


AFFECTIONS    OF    THE    TESTIS. 


Diagnosis. — The  recognition  of  hydrocele  is  as  a  rule  not  diffi- 
cult. The  principal  conditions  which  may  be  confounded  are  prin- 
cipally hernia,  syphilitic  orchitis,  sarcoma,  and  chronic  haematocele. 

The  characteristic  pear  or  ovoid  shaped  growth  with  a  history  of 
slow  growth  beginning  at  the  bottom  of  the  scrotum  and  the  trans- 
luency  or  "light  test."  The  testis  is  usually  found  posteriorly  and 
at  the  upper  part  of  the  tumor;  if  the  condition  be  of  long  standing 
the  thickness  of  the  sac  may  give  absolutely  no  translucency. 

The  differential  points  in  the  diagnosis  of  hydrocele  and  hernia 
are  as  follows:  in  hydrocele  there  is  no  impulse  on  coughing.  The 
position  or  size  of  the  tumor  is  not  altered  with  the  patient  standing 
or  lying  down;  in  hydrocele  the  tumor  presents  dullness  on  per- 
cussion, while  in  the  hernia  there  is  distinct  resonance.  In  hernia 
the  growth  begins  from  above  downward  where  it  is  largest  and 
doughy,  where  in  hydrocele  the  tumor  begins  from  the  bottom  of 
the  sac,  grows  upward,  and  is  usually  firm  in  consistency. 


Fig.  .41. — Hayden's  aspirator  and  trocar. 


Etiology. — -Gonorrhoeal  epididymitis  and  epididymoorchitis  may 
give  rise  to  chronic  hydrocele.  These  affections,  whether  due  to 
gonorrhoea  or  other  causes,  specific  or  malignant,  may  be  accom- 
panied by  a  chronic  effusion  in  the  tunica  vaginalis,  may  also 
follow  varicocele  and  may  also  occur  as  a  complication  of  dropsy. 
Hydrocele  is  very  frequently  caused  by  traumatism. 

Treatment  of  hydrocele  may  be  either  palliative  or  radical. 
The  palliative  method  simply  consists  of  temporary  removal  of  the 
fluid  by  tapping,  using  for  this  purpose  an  ordinary  medium  sized 
aspirating  needle  or  trocar.  (Fig.  41.)  The  part  having  been  ren- 
dered aseptic,  the  tumor  is  grasped  by  the  left  hand  on  its  posterior 


RADICAL    METHOD    OF    TREATMENT.  1 43 

surface  and  the  skin  drawn  tense.  The  trocar  is  then  made  to 
enter  at  the  junction  of  the  lower  and  middle  third  of  the  tumor 
for  a  distance  of  about  half  an  inch  in  depth.  The  fluid  is  then 
drawn  off  and  the  puncture  closed  over  with  a  piece  of  sterilized 
gauze  or  cotton,  held  in  place  with  collodion.  In  most  cases  this 
procedure  is  attended  with  refilling  of  the  sac  within  the  course  of  a 
few  months. 

Treatment  by  means  of  caustics  and  irritants,  intended  to  oblit- 
erate the  sac  is  at  the  present  day  no  longer  resorted  to.  It  is  merely 
mentioned  in  order  to  condemn  it. 

Radical  Method  of  Treatment  .^Several  operations  have  been 
devised  in  order  to  produce  a  radical  cure;  chief  of  which  are 
Doyen's,  Von  Bergmann's,  and  Volkmann's. 

The  Doyen  operation  consists  of  a  complete  inversion  of  the  sac. 
The  technic  of  the  operation  is  as  follows:  The  pubes  are  shaved, 
etc.,  the  patient  is  etherized,  the  part  scrubbed  with  soap  and  w^ater, 
rinsed  with  alcohol,  and  washed  with  a  sublimate  solution.  In- 
cision is  made  through  the  scrotal  tissues  over  the  convexity  of  the 
tumor  by  transfixion.  The  hydrocele  sac  is  then  exposed,  separated 
from  its  adhesions,  and  delivered  from  the  scrotal  cavity.  An 
incison  is  made  into  the  distended  sac,  the  contents  evacuated,  and 
the  tunica  vaginalis  sufficiently  incised  to  allow  its  complete  inver- 
sion, and  the  edges  held  in  apposition  by  a  few  catgut  sutures.  It 
is  fehen  replaced  in  the  scrotum,  with  the  result  that  the  testicle 
lies  outside  of  the  tunica  between  it  and  the  scrotal  wall.  The 
serous  surface  of  the  tunica  vaginalis  faces  outward  and  soon 
becomes  fused  with  its  loose  connective  tissue.  The  wound  is 
then  flushed  with  warm  saline  solution  and  the  w^ound  of  the 
scrotum  closed  with  interrupted  silk-worm  sutures.  This  operation 
is  rarely  attended  with  any  bleeding  and  good  results  almost 
invariably  follow  its  performance. 

Volkmann's  opera.tion  consists  of  making  a  vertical  incision 
about  three  inches  in  length  over  the  middle  of  the  tumor  tissues, 
carefully  dissecting  down  to  the  tunica  vaginalis.  The  hydrocele 
sac  is  then  punctured,  and  a  full  incision  made  of  the  sac  by  means 


144  AFFECTIONS    OF    THE    TESTIS. 

of  a  pair  of  blunt  scissors.  The  edges  of  the  tunica  and  the  corre- 
sponding edges  of  the  scrotum  wound  are  then  sutured.  The  hydro- 
cele cavity  is  swabbed  with  pure  carbolic  acid  and  the  drainage 
tube  inserted,  the  parts  brought  together,  or  the  wound  may  be 
packed  with  iodoform  gauze.  This  operation  has  been  followed  by 
recurrence  of  the  hydrocele  but  in  most  cases  it  is  followed  by  a 
radical  cure. 

The  Von  Bergmann  operation  consists  in  resection  of  the  sac, 
and  has  been  found  a  satisfactory  and  successful  method.  After 
the  patient  has  been  etherized  and  the  field  of  operation  rendered 
aseptic,  a  vertical  incision  is  made  over  the  anterior  surface  of  the 
hydrocele,  the  hydrocele  is  then  liberated  from  any  existing  adhe- 
sions, and  delivered  from  the  scrotal  sac.  A  free  incision  is  then 
made  into  it  and  the  parietal  layer  of  the  tunica  vaginalis  is  com-, 
pletely  resected  within  a  1/2  inch  from  the  testes  and  epididymis. 
After  the  bleeding  points  have  been  thoroughly  controlled  the  edges 
of  the  wounds  are  brought  into  apposition  and  sutured. 

Encysted  hydrocele  of  the  epididymis  (or  spermatocele)  may 
accompany  hydrocele  of  the  tunica  vaginalis,  or  may  exist  by  itself. 
The  testes  may  also  be  the  seat  of  an  encysted  hydrocele.  These 
cysts  may  be  subserous  and  parenchymatous,  or  large  and  small. 
The  subserous  cysts  are  usually  multiple  (multilocular) ;  are  about 
the  size  of  a  pea,  and  are  found  around  the  upper  part  of  the  globus 
major.  The  contained  fluid  may  be  clear  or  milky.  Cysts  of  the 
testicle  itself  are  rare. 

Diagnosis. — Encysted  hydrocele  of  the  epididymis  is  usually 
diagnosed  by  its  position,  the  number  of  cysts,  and  the  character  of 
fluid  contained  which  may  be  determined  by  the  use  of  a  hypodermic 
needle. 

Treatment. — If  the  encysted  hydrocele  be  small,  tapping  is 
usually  all  that  is  necessary.  Larger  cysts  should  be  treated  by 
radical  operation. 

Hydrocele  of  the  Spermatic  Cord. — This  occurs  in  two  forms, 
the  diffused  and  encysted.  The  diffused  form  consists  of  a  serous 
effusion  into  the  loose  connective  tissue  of  the  cord  and  may  escape 


HiEMATOCELE.  I45 

the  notice  of  the  patient  until  it  attains  considerable  size.  The 
spermatic  cord  will  be  felt  to  be  much  larger,  resembling  very  much 
an  omental  hernia.  It  is  usually  pyramidal  in  shape,  broader  at 
the  base  than  at  the  top,  and  is  attended  with  very  little  discomfort. 
Its  chief  distinguishing  features  from  that  of  a  hernia  are:  that  the 
tumefaction  is  firmer  and  dull  on  percussion,  with  slight  fluctuation. 
The  impulse  on  coughing  is  also  a  characteristic,  as  in  hydrocele 
of  the  cord  there  is  but  very  little  downward  movement  and  the 
gurgling  sensation  is  absent.  Hydrocele  may  also  be  recognized  by 
its  translucency. 

Treatment. — Consists  principally  of  making  small  multiple 
punctures,  through  which  the  fluid  is  evacuated,  and  subsequent 
pressure  often  producing  a  perfect  cure.  Sometimes  an  injection 
of  tincture  of  iodine  or  carbolic  acid  may  be  tried.  If  the  cysts 
be  multilocular  and  the  palliative  method  fails,  one  of  the  radical 
operations  should  be  resorted  to. 

Strangulation  of  the  testes  and  epididymis  from  torsion  of 
the  cord  fortunately  very  rarely  occurs.  The  testicle,  which  may 
be  in  the  inguinal  canal  or  scrotum,  suddenly  becomes  swollen  and 
painful.  It  is  usually  seen  in  young  persons  in  whom  there  is  some 
evidence  of  undescended  testicles.  The  seat  of  the  tumefaction 
depends  entirely  on  the  location  of  the  testicles.  Besides  the 
swelling  the  part  is  red  and  oedematous.  Torsion  of  the  cord 
strongly  resembles  strangulation,  hernia,  and  appendicitis  in  its 
symptomatology.  The  direct  and  exciting  cause  is  violent  and 
sudden  muscular  strain  or  effort.  Unless  this  state  of  affairs  is 
immediately  relieved,  gangrene  of  the  testes  results. 

Treatment. — If  the  testicle  is  in  the  scrotum,  torsion  of  the  cord 
may  be  relieved  by  taxis.  Damage  of  the  testicles,  such  as  a 
hemorrhagic  infarct  or  gangrene,  demand  prompt  surgical  inter- 
vention and  extirpation  of  the  destroyed  testicle. 

HiEMATOCELE. 

Haematocele  is  an  extravasation  of  blood  into  the  tunica  vaginalis, 
the  testes,  epididymis,  or  cord,  or  into  all  combined,  and  may  be  acute 
10 


14^)  AFFECTIONS    OF    THE    TESTIS. 

or  chronic.  It  generally  occurs  as  an  immediate  consequence  ol 
injury  of  the  scrotum;  sometimes  it  arises  without  any  assignable 
cause.  There  is  swelling  of  the  part  which  comes  immediately  or 
soon  after  the  receipt  of  the  injury,  it  resembles  hydrocele  as 
regards  shape.  At  first  the  tumor  is  soft  and  fluctuation  may  be 
detected,  but  when  the  blood  coagulates  it  resembles  in  character 
a  solid  growth. 

Treatment. — In  a  recent  case  the  first  indications  are  to  arrest 
the  flow  of  blood  and  relieve  pain.  The  horizontal  posture  with 
testicles  raised,  is  necessary;  the  iced  bag  and  cold  lotion  must  be 
applied  and  if  the  blood  remains  fluid  for  a  long  time,  tapping  may 
be  performed.  In  chronic  cases  if  there  are  signs  of  suppuration, 
a  free  incision  should  be  made  into  the  vaginal  sac,  and  the  cysts 
and  the  clot  turned  out.  Then  follows  the  usual  treatment  to 
promote  healing  by  granulation. 

Haematocele  of  the  epididymis,  testes,  and  cord  is  very  rare; 
it  may  be  diffused  or  encysted.  The  principles  of  treatment  are 
the  same. 

ATROPHY. 

Atrophy  of  the  testes  is  an  affection  frequently  seen.  It  has 
been  ascribed  to  a  great  variety  of  causes  chief  of  which  are  mal- 
position or  ectopia,  and  abnormal  retention  when  seen  in  the  young. 
Degenerative  process  of  testicle  may  also  occur  in  syphilis,  gonor- 
rhoea, hydrocele  and  haematocele,  and  certain  forms  of  hsemiplegia. 
Atrophy  of  the  testes  has  been  observed  in  cases  where  there 
has  been  a  long  continued  use  of  certain  drugs,  e.g.,  bromide  of 
potassium  and  belladonna. 

TUBERCULOSIS. 

The  testicle  is  frequently  the  seat  of  tubercular  infiltration,  in 
consequence  of  which  its  function  is  destroyed.  The  epididymis 
is  usually  affected  primarily  and  secondarily  involves  the  body  of 
the  testicle.  It  may  also  occur  from  a  tubercular  deposit  in  one 
of  the  other  genito-urinary  organs,  or  as  a  result  of  a  general  tuber- 


TUBERCULOSIS.  1 47 

culosis  invading  the  testicles  by  the  blood  carried  to  it,  probabl}' 
by  the  spermatic  artery,  or  it  may  travel  by  way  of  the  vas  deferens, 
lodging  the  tubercle  baciUi  in  the  epididymis. 

It  is  supposed  by  many  that,  when  the  prostate,  bladder,  or 
adjacent  structures  are  primarily  involved,  the  lymphatics  convey 
the  infection.  Hereditary  tendencies  undoubtedly  predispose  to 
tubercular  disease  of  the  testes  from  such  local  causes  as  trauma- 
tism, gonorrhoea,  etc.  The  age  at  which  this  affection  is  most 
commonly  found  is  from  15  to  50  years,  which  is  the  period  of 
functional  activity. 

The  course  may  be  slow  or  rapid.  One  or  two  small  nodules 
(each  about  the  size  of  a  pea)  in  the  head  of  the  epididymis  may 
occasion  no  trouble  for  years,  when  suddenly  from  some  exciting 
cause  perhaps,  they  may  suddenly  grow  larger,  coalesce,  undergo 
caseation  and  suppuration  with  abscess  formation. 

The  seminal  fluid  is  apt  to  be  tinged  with  blood  at  this  time. 
The  scrotal  tissues  are  of  a  deep  red  or  bluish  color  with  a  number 
of  fistulous  openings.  When  only  one  of  the  testicles  is  attacked, 
the  other  usually  sooner  or  later  becomes  involved. 

The  chronic  type  of  tubercular  disease  of  the  testes  is  as  a  rule 
attended  with  little  or  no  pain.  The  swelling  slowly  increases,  is 
nodular  in  character.  This  process  may  go  on  for  months  or  even 
for  several  years  before  it  undergoes  caseation,  abscess  formation, 
and  subsequent  fistulae.  This  affection  may  be  solely  confined  to 
the  epididymis  or  it  may  involve  the  testicle. 

The  presence  of  hydrocele  is  said  to  be  found  in  one-third  of  the 
cases  of  tubercle  of  the  testes.  Evidences  of  involvement  of  the 
prostate  and  seminal  vesicles  may  be  ascertained  by  digital  exami- 
nation in  the  rectum.  The  vas  deferens  is  almost  invariably 
attacked  in  the  tubercle  invasion  of  the  testes.  It  is  more  or  less 
thickened,  irregular,  and  nodular,  with  loss  of  its  spermatogenic 
function.     If  both  testicles  are  infiltrated,  complete  sterility  occurs. 

Prognosis. — Even  under  the  most  favorable  influence,  climatic 
or  otherwise,  tuberculosis  of  the  testicle  rarely  becomes  permanently 
cured  without  an  operation. 


148  AFFECTIONS    OF   THE    TESTIS. 

Treatment. — Palliative  measures,  e.g.,  change  of  climate,  drugs, 
— cod-liver  oil,  hypophosphates,  creosote,  etc.,  may  be  instituted  if 
the  condition  is  recognized  early,  but  even  then,  in  most  cases,  these 
only  retard  the  degenerative  processes  which  almost  invariably 
occur  from  the  least  exciting  cause. 

Surgical  measures  are  indicated  where  the  patient  cannot  afford 
to  go  away,  and  is  poorly  housed  and  nourished,  in  which  instance 
there  is  no  other  alternative  but  an  operation,  so  as  to  arrest  the 
further  progress  of  the  disease.  The  indurated  masses  in  the 
epididymis  and  testes  should  be  curetted  and  packed!  with  iodoform 
gauze  and  allowed  to  heal  by  granulation.  All  sinuses  should  be 
enlarged,  curetted,  and  packed  with  iodoform  ^auze.  Castration 
is  necessary  in  advanced  cases  in  which  the  ordinary  measures  have 
failed  to  arrest  the  invasion  of  the  tubercle,  and  where  there  are 
numerous  fistulas  and  the  body  of  the  testicle  involved,  or  where 
here  is  a  purulent  hydrocele. 

CYSTIC  SARCOMA. 

This  affection  is  comparatively  rare  and  occurs  in  early  life,  i.e., 
between  the  ages  of  30  and  40,  and  usually  attacks  but  one  testis, 
running  its  course  to  a  fatal  termination  in  from  i  to  2  years.  The 
growth  begins  insidiously  and  is  not  attended  with  any  pain.  The 
tumor  is  hard  and  smooth  and  strongly  resembles  gumma  of  the 
testicle  (excluded  by  antisyphilitic  measures)  and  may  or  may  not  be 
complicated  with  hydrocele. 

Treatment. — This  condition  imperatively  demands  prompt  and 
complete  removal  of  the  affected  testicle. 

CARCINOMA. 

This  form  of  tumor  of  the  tesicle  is  observed  about  middle  life 
and  is  usually  of  the  soft  or  encephaloid  type.  The  glands  of  the 
groin  are  indurated,  the  cord  thickened,  the  growth  hard  and 
smooth,  later  undergoing  softening,  and  perhaps  adhering  to  the 
scrotal  covering,  and  eventually  sloughing  of  these  tissues  through 
which  the  tumor  protrudes. 


CASTRATION.  I 49 

Treatment. — Complete  extirpation  of  the  testicle,  dividing  the 
cord  as  far  up  as  possible.  The  inguinal  glands  should  also  be 
removed,  as  well  as  the  scrotal  tissues  of  the  affected  side. 

The  other  tumors  of  the  testicle  less  frequently  found  arej- 
enchondroma  (cartilaginous)  and  dermoid  cysts. 

CASTRATION. 

Technic. — After  taking  due  antiseptic  precautions  and  etherizing 
the  patient,  proceed  as  follows:  a  longitudinal  incision  is  made  over 
the  anterior  scrotal  wall  down  to  the  glistening  surface  of  the  tunica 
vaginalis.  The  adhesions  are  now  broken  up  and  the  entire  mass 
is  delivered  from  the  scrotal  sac.  The  tunica  is  then  carefully 
opened,  the  cord  stripped  of  its  serous  covering  as  high  up  as  possible 
and  ligated  with  heavy  silk  or  catgut.  The  cord  is  then  transfixed, 
ligating  each  half  separately  so  as  to  prevent  slipping.  A  final  liga- 
ture is  next  tied  completely  around  the  cord  and  it  is  then  cut.  It 
is  well  then  to  pierce  the  stumps  with  a  needle  dipped  in  carbolic 
acid.  The  bleeding  points  should  now  be  controlled,  the  parts 
wiped  dry,  and  the  wound  closed  with  interrupted  silkworm  sutures, 
or  the  dependent  portion  left  open  for  drainage  where  this  is  deemed 
advisable.  If  the  tunica  and  scrotal  tissues  are  also  involved  in  the 
infective  process,  the  first  incision  should  extend  from  the  external 
ring  all  the  way  down  to  the  bottom  of  the  scrotum  so  as  to  remove 
all  the  diseased  areas.  The  operation  otherwise  is  then  performed 
as  just  described. 

Surgical  Treatment  of  Undescended  Testis. — Operation  is 
justifiable  when  we  consider  that  (i)  a  potential  if  not  an  actual 
hernia  is  always  present;  (2)  that  strangulation  and  torsion  of  the 
spermatic  cord  are  strongly  predisposed  to  by  this  condition;  (3) 
that  an  inguinal  testis  is  peculiarly  liable  to  trauma  from  external 
violence  and  from  muscular  exertion ;  (4)  that  imperfectly  descended 
testes  appear  to  be  affected  by  malignant  neoplasms  oftener  than 
when  in  their  normal  habitat  in  the  scrotum;  (5)  that  psychic  dis- 
turbances may  arise  later;  (6)  that  even  should  operation  fail  to 


150  AFFECTIONS    OF    THE    TESTIS. 

lead  to  further  development  of  the  gland  it  will  usually  do  no  harm 
by  way  of  disturbance  of  function,  for  it  has  been  shown  that  practic- 
ally all  misplaced  testes  lack  the  spermatogenic  function.  The  most 
favorable  age  for  operation  is  from  5  to  12  years.  Orchidopexy  or 
fixing  the  testis  in  the  scrotum  is  the  operation  of  choice.  Removal 
of  one  testis  is  rarely  justifiable  and  castration  never  unless  the 
gravest  complications  demand  it. 

VARICOCELE. 

Varicocele  consists  of  a  varicose  condition  of  the  spermatic  veins 
(pampiniform  plexus)'  and  is  much  more  frequently  met  with  on  the 
left  side  than  the  right.  It  is  more  often  found  in  adolescents,  up 
to  about  the  thirtieth  year. 

Etiology. — The  occurrence  of  varicocele  on  the  left  side  is 
accounted  for  by  the  fact  that  the  left  spermatic  vein  enters  the 
inferior  vena  cava  indirecdy  through  the  left  renal  vein,  whereas 
on  the  right  side  the  spermatic  vein  enters  directly  into  the  inferior 
vena  cava;  consequently  the  blood  pressure  on  the  left  side  is 
greater  than  on  the  right.  It  is  further  claimed  that  the  sigmoid 
flexure  immediately  overlies  the  vein  and  when  it  becomes  distended 
with  faecal  accumulations  there  is  more  or  less  compression. 

Symptoms. — On  inspection  the  testicle  on  the  affected  side  will 
be  found  to  hang  lower  than  normal;  in  its  appearance  and  to 
the  touch  it  resembles  a  bundle  of  earth  worms.  When  the  patient 
lies  down,  the  tumefaction  disappears,  resembling  in  this  respect  an 
inguinal  hernia.  The  subjective  symptoms  are  as  follows:  The 
patient  complains  of  a  sensation  of  weight  and  tension  in  the 
scrotum.  The  pain  sometimes  associated  with  these  conditions, 
radiating  up  along  the  spermatic  cord  to  the  groin  or  to  the  loins 
and  sometimes  toward  the  kidneys,  m^ay  be  dull  and  sharp  in 
character  and  aggravated  by  exercise  or  prolonged  sexual  excite- 
ment. Atrophy  of  the  testicle  due  to  impeded  return  circulation 
is  often  the  sequel  of  varicocele.  Hydrocele  is  another  not  uncom 
mon  complication. 


VARICOCELE.  151 

Diagnosis. — Recognition  of  varicocele  is  never  difficult;  palpa- 
tion and  inspection  of  the  worm-like  mass  are  usually  all  that  is 
required.  Examination  may  be  supplemented  by  compressing  upon 
the  abdominal  ring;  the  patient  being  in  the  erect  posture.  The 
Aeins  will  be  felt  to  be  empty,  but  upon  withdrawing  the  pressure . 
the  veins  are  again  suddenly  filled  up  which  can  be  readily  felt, 
thereby  distinguishing  it  from  a  hernia. 

Treatment.— The  treatment  of  varicocele  may  be  either  pallia- 
tive or  radical.  The  palliative  treatment  consists  of  local  support 
by  means  of  a  well  fitting  suspensory  bandage,  or  alternate  hot  and 
cold  douches  may  be  given  the  patient  with  much  relief.  He 
should  be  instructed  to  empty  his  bowels  regularly,  avoid  exercise 
or  sexual  excitement.  The  most  satisfactory  method  of  dealing 
with  the  conditions  is  by  radical  measures.  Probably  the  best 
operation  for  varicocele  is  the  open  one,  the  advantages  of  which 
are  obvious. 

The  Open  Operation. — This  may  be  performed  under  local  or 
general  anaesthetics.  The  parts  having  been  prepared,  the  surgeon 
seeks  the  raphe  of  the  scrotum,  the  tissues  are  drawn  tense,  and  he 
makes  a  longitudinal  incision  for  half  an  inch  midway,  between  it 
and  the  external  border  of  the  scrotal  sac,  directly  over  the  veins, 
being  extremely  careful  to  avoid  any  injury  to  the  vas  deferens 
which  lies  under  the  veins  and  is  perceptible  to  the  fingers  as  a 
lirm  cord-like  structure. 

The  covers  of  the  cord  are  then  carefully  dissected  until  the 
sheath  of  the  veins  is  reached,  which  is  recognized  by  its  shiny, 
light  grayish  color,  overlying  the  blue  veins  now  brought  into  view. 
The  plexus  is  now  separated  from  the  tissues  by  the  fingers,  and 
strong  ligatures  of  silk  or  catgut,  are  applied,  first  tying  it  below 
and  then  for  a  distance  of  about  i  1/2  to  2  inches  apart,  tying  it 
above,  and  leaving  the  ends  of  the  ligature  material  long.  The 
veins  are  then  severed  between  the  ligatures,  thus  excising  about 
two-thirds  of  the  plexus,  leaving  one-third  to  continue  its  function. 
The  cut  ends  of  the  vein  stumps  are  then  brought  together,  the  ends 
of  the  ligature  tied   and  cut  off  short.     In  bringing  the  stumps 


152  AFFECTIONS    OF    THE    TESTIS. 

together,  it  is  well  to  reinforce  the  union  by  one  or  two  sutures 
into  the  overlying  sheath  and  veins. 

Another  method  brought  recently  into  vogue  is  the  so-called 
HIGH  OPERATION,  which  is  as  follows:  An  incision  is  made  for  a 
distance  of  about  2  inches  directly  over  the  inguinal  canal,  and  the 
plexus  of  veins  is  brought  up  into  the  wound  by  the  surgeon's 
finger  through  the  inguinal  ring  and  the  distended  veins  are  readily 
brought  into  view.  The  succeeding  steps  are  the  same  as  the 
ordinary  open  operation  Just  described. 

The  method  of  subcutaneous  ligation  of  the  veins  is  now 
rarely  resorted  to  owing  to  the  danger  of  puncturing  the  veins, 
with  resultant  haematocele.  The  encysted  ligations  are  very  apt  to 
be  the  cause  of  persistent  neuralgia  and  relapses  of  the  varicocele 
are  very  frequent. 


CHAPTER  VIII. 
AFFECTIONS  OF  THE  PROSTATE  GLAND. 

The  prostate,  which  is  an  accessory  sexual  organ,  is  about  the 
size  and  shape  of  a  horse-chestnut  and  is  intimately  connected  with 
the  bladder  and  urethra.  It  is  readily  accessible  to  touch  by  way 
of  the  rectum,  by  which  its  upper  surface  can  be  distinctly  felt. 
It  consists  of  a  mucous  membrane,  longitudinal  and  deep  circular 
fibres,  which  contain  the  glandular  substance,  the  whole  being 
invested  by  a  firm  dense  capsule  of  fibrous  tissue.  Its  weight  is 
approximately  4  to  6  drams.  It  surrounds  the  vesical  end  of  the 
urethra,  immediately  in  front  of  the  bladder,  and  consists  of  two 
lateral  lobes.  The  gland  is  pierced  by  the  urethra,  which  segment 
is  referred  to  as  the  prostatic  portion.  The  ejaculatory  ducts  enter 
the  gland  and  open  into  the  urethra  on  each  side  of  the  sinus 
pocularis.  There  is  a  medium  portion  connecting  the  two  lateral 
lobes  which  has  been  erroneously  described  as  the  third  lobe, 
which  when  it  exists  prominently  is  considered  abnormal.  A  pro- 
longation of  the  deep  perineal  fascia  encloses  the  gland.  The  blood 
supply  is  through  the  vesico-prostatic  artery,  a  branch  of  the  inferior 
vesical,  also  from  the  internal  pubic  and  middle  hemorrhoidal 
branches.  The  veins  of  the  prostate  are  known  as  the  prostatic 
plexus.  The  nervous  supply  is  derived  from  the  sacral  sympa- 
thetic, and  from  the  loth,  nth,  and  12th  dorsal,  the  ist  and  2nd 
sacral,  and  the  5th  lumbar. 

Acute  Prostatitis. — Inflammation  of  the  prostate  is  always  a 
serious  condition  when  it  occurs  as  a  complication  of  urethritis. 
It  may  develop  at  any  time  during  the  attack  of  gonorrhoea,  but 
usually  occurs  at  the  terminal  stage.  Epididymitis  may  precede 
or  co-exist  with  the  infection  of  the  prostate.  It  is  claimed  by  some 
that  this  affection  occurs  in  70  per  cent,  of  all  cases  of  posterior 
urethritis. 

153 


154  AFFECTIONS    OF    THE    PROSTATE    GLAND. 

Varieties. — The  two  forms  of  prostatic  inflammation  are  the 
follicular  and  parenchymataus  varieties.  In  the  follicular  form, 
small  multiple  abscesses  are  likely  to  develop  as  a  result  of  the 
follicular  suppuration.  In  acute  parenchymatous  prostatitis,  the 
whole  grandular  structure  is  involved  and  unless  resolution  occurs 
it  frequently  results  in  the  formation  of  a  large  abscess. 

Etiology. — The  causes  are  predisposing  and  exciting.  The 
predisposing  factors  are  tuberculosis  and  gonorrhoea.  The  exciting 
causes  are  always  more  or  less  uncertain.  The  chief  causes  to 
^vhich  infection  of  the  prostate  has  been  attributed  are  strong 
injections  and  irrigations,  sexual  indulgence,  and  ungratified  sexual 
excitement  during  an  attack  of  urethritis. 

Symptoms. — The  symptoms  as  a  rule  are  marked.  The  patient's 
first  complaint  is  of  a  sense  of  fullness  with  possibly  slight  pain  in  the 
rectum.  The  pain  soon  becomes  bearing  down  and  throbbing  in 
character.  With  this  there  may  be  certain  febrile  disturbances  and 
sometimes  retention  of  urine.  Under  proper  treatment,  resolution 
should  take  place  in  from  3  to  4  weeks. 

Treatm.ent.— The  patient  should  be  advised  to  rest  in  bed,  the 
bowels  kept  regular  by  saline  laxative  or  daily  enema,  and  he  should 
be  given  internally  salol  or  urotropin.  Locally  the  treatment  consists 
of  hot  or  cold  rectal  irrigations  about  3  times  daily,  followed  by  the 
insertion  of  an  opium  and  belladonna  or  ichthyol  suppositor}\  After 
the  acute  inflammatory  symptoms  have  begun  to  subside,  which 
will  be  at  the  end  of  about  10  days,  massage  of  the  prostate  is  then 
effective  in  hastening  resolution,  but  must  always  be  gentle,  other- 
wise there  is  danger  of  inducing  epididymitis.  The  application  of  cold 
is  also  very  beneficial  in  these  cases.  The  Kemp  prostatic  cooler  is 
an  exceedingly  useful  apparatus  for  this  purpose.  It  is  arranged 
in  such  a  manner  so  as  to  allow  a  constant  flow  of  cold  water  about 
the  gland  by  means  of  an  intake  and  outflow  tube.  Heat  may  also  be 
applied  in  this  manner. 

Abscess  of  the  Prostate. — Frequently,  multiple  small  abscesses 
or  a  large  single  abscess  of  the  prostate  occur.  Rectal  examination 
under  such  circumstances  presents  the  usual  symptoms  of  abscess. 


CHRONIC    PROSTATITIS.  1 55 

e.g.,  swelling,  heat,  and  fluctuation,  and  tenderness  over  the  prostate 
gland. 

Diagnosis. — Digital  rectal  examination  is  essential  in  making  a 
positive  diagnosis.  The  abscess  will  be  found  large  and  somewhat 
soft,  feverish,  and  tender  to  the  touch.  A  large  fluctuating  tumor 
will  be  detected  where  the  prostate  would  be  normally  found. 

Treatment. — In  dealing  with  an  abscess  of  the  prostate,  sur- 
gical intervention  is  imperative.  A  small  incision  is  made  in  the 
perineum,  with  the  cutting  edge  of  the  bistoury  turned  upward 
toward  the  apex  of  the  prostate.  The  abscess  cavity  is  now  readily 
opened,  pus  evacuated,  the  wound  flushed  with  bichloride  solution,  and 
th€  cavity  packed  with  iodoform  gauze.  If  the  pus  is  deep  seated 
the  body  of  the  prostate  must  be  reached  by  blunt  dissection  and 
treated  in  the  manner  just  described.  Unless  the  abscess  cavity  is 
drained,  spontaneous  rupture  resulting  in  fistulee  will  in  most  in- 
stances occur.  The  abscess  ruptures  into  the  urethra  in  a  majority 
of  cases  and  may  also  burrow  into  the  rectum  which  is  the  next  most 
favorable  outlet.  In  a  small  percentage  of  cases  the  perineum  may 
be  the  seat  of  the  rupture.  In  cases  of  spontaneous  rupture  the 
subsequent  treatment  consists  of  prostatic  massage  and  irrigations, 
of  preferably  silver  nitrate  solutions.  Pyaemia  has  been  known  to 
result  from  abscess  of  the  prostate. 

Chronic  prostatitis  usually  originates  as  a  result  of  an  acute 
inflammation  of  the  prostate,  particularly  of  the  follicular  type, 
but  may  also  be  the  termination  of  a  posterior  urethritis.  Pathologi- 
cally the  organ  will  be  sw^ollen  and  soft.  The  ducts  of  the  gland  are 
always  large  and  patulous  and  the  crypts  and  follicles  often  contain 
pus. 

Symptoms. — The  symptoms  of  chronic  prostatitis  are  largely 
those  of  chronic  posterior  urethritis.  The  passage  of  the  urine  may 
be  attended  with  scalding  and  there  is  partial  or  complete  impotence. 
With  this  phenomena  the  patient  presents  more  or  less  neurotic 
symptoms,  feels  depressed  over  his  condition,  there  is  loss  of  sleep, 
perhaps  mental  irritability,  and  loss  in  weight.  Sufferers  are  often 
referred  to  as  sexual  neurasthenics. 


156  AFFECTIONS    OF    THE    PROSTATE    GLAND. 

Prostatorrhcea  is  defined  as  a  condition  characterized  by  more 
or  less  involuntary  discharge  from  the  gland,  in  the  effort  to  rid  itself 
of  the  over  secreted  material.  This  secretion  may  flow  from  the 
urethra  after  stool  and  urination  or  may  be  voided  with  the  urine, 
and  sometimes  even  after  an  erection.  The  escaping  fluid  is  sticky 
and  glary  in  character  and  is  due  to  muscular  pressure  upon  the 
prostate,  emptying  the  prostatic  crypts  or  follicles.  . 

PATHOLOGY.  1 

The  posterior  urethra  being  lined  with  squamous  epithelium  of  the 
transitional  type,  a  direct  continuation  of  that  lining  the  bladder  is 
not  so  susceptible  to  changes  similar  to  those  met  with  in  the  anterior 
urethra.  The  presence  of  the  prostate  gland,  with  its  numerous 
ducts  emptying  directly  into  the  posterior  urethra,  give  a  most 
favorable  site  for  the  lodgment  and  growth  of  the  gonococcus,  so 
that  the  pathology  of  chronic  posterior  urethritis  is  essentially  the 
pathology  of  chronic  prostatitis.  Depending  upon  the  extent  of 
involvement,  three  varieties  of  chronic  gornorrhoeal  prostatitis  are 
recognized,  the  catarrhal,  follicular,  and  parenchymatous. 

The  catarrhal  and  the  follicular  varieties  are  the  most  frequent 
forms  met  with  in  chronic  gonorrhoea,  and  the  pathological  process 
is  here  the  same  as  in  the  anterior  urethra.  The  gonococcus  invades 
the  ducts  of  the  prostate,  considerable  exudate  results,  shutting  off 
the  lumen  of  the  duct.  The  contents  are  thus  retained  within  the 
ducts,  constituting  the  catarrhal  prostatitis,  or,  what  is  probably 
more  frequent,  the  glands  themselves  become  inflamed,  either  with 
or  without  occlusion  of  the  prostatic  ducts,  giving  rise  to  the  follic- 
ular prostatitis.  Clinically,  in  this  condition  symptoms  may  be 
entirely  absent  at  the  time  of  exam^ination,  the  urine  may  even  be 
free  of  solid  elements,  but  the  history  of  the  occurrence  of  a  slight 
mucoid  or  mucopurulent  discharge  at  various  intervals,  lasting  for 
a  few  days,  especiaUy  after  the  free  imbibition  of  alcohol  or  after 
sexual  intercourse,  perhaps  a  little  frequency  of  urination  or  fre- 

^  Abstracted  from  an  article  on  "Chronic  Gonorrhcea,"  by  Uhle  and  MacKinney, 
A^.  Y.  Med.  Journal.,  Jan.  10,  1909- 


PATHOLOGY.  1 57 

quent  nocturnal  pollutions  with  sexual  irritability,  are  some  of 
the  symptoms  which  should  lead  to  a  thorough  examination  of  the 
prostate. 

The  DIAGNOSIS  of  this  condition  rests  upon  the  examination  of  the 
prostate  by  the  rectum,  the  microscopical  examination  of  the  expressed 
prostatic  secretion,  and  the  occurrence  of  solid  bodies  in  the  third 
urine  of  the  three-glass  test  after  a  thorough  prostatic  massage.  In 
the  catarrhal  and  the  mild  follicular  varieties  the  prostate  may  feel 
normal,  but  in  a  well-defined  case  the  gland  is  enlarged,  irregular  in 
contour,  as  a  whole  dimished  in  consistency,  and  tender.  At  several 
points  nodules  of  firmer  consistency  may  be  felt  and  represent  fol- 
licles distended  with  retained  inflammatory  products.  From  the 
examination  of  many  normal  prostates  it  will  be  noted  that  in  normal 
prostates  the  left  lobe  is  apt  to  be  larger  than  the  right,  a  point  which 
should  be  taken  into  account  in  the  diagnosis  and  treatment. 

The  quantity  of  secretion  appearing  at  the  meatus,  after  massage 
of  the  prostate,  varies  from  one  to  several  drops.  Normally  this 
fluid  is  turbid,  somewhat  milky  in  color,  slightly  tenacious,  faintly 
alkaline  in  reaction,  and  dries  white  upon  a  slide.  Under  patho- 
logical conditions  its  macroscopic  appearance  may  remain  unaltered 
or  it  may  become  thicker,  more  tenacious,  slightly  yellow,  and  con- 
tain small  solid  shreds  best  seen  when  the  secretion  is  dried.  Micro- 
scopical examination  of  the  normal  stained  secretion  shows  the 
presence  of  a  structureless  granular  material,  a  very  few  epithelial 
cells,  leucocytes,  and  spermatozoa.  In  pathological  conditions 
there  is  always  an  abundance  of  leucocytes,  desquamated  epithelium, 
and  bacteria.  Among  the  latter  are  staphylococci,  short  chains  of 
streptococci,  few  bacilli,  not  infrequently  intracellular  and  extra- 
cellular gonococci,  and  small  diplococci,  which  decolorize  by  Gram's 
method.  The  most  important  points  to  be  observed  in  demonstrat- 
ing gonococci  in  these  cases  of  long  duration  are  to  thoroughly 
massage  the  prostate,  to  look  long  and  carefully,  and  if  not  success- 
ful, employ  the  provocation  instillations  of  silver  nitrate. 

After  thoroughly  irrigating  the  urethra,  allow  part  of  the  clear 
fluid  to  remain  in  the  bladder,  then  massage  the  prostate,  and  have 


T58  AFFECTIONS    OF    THE    PROSTATE    GLAND. 

the  con  ten  Is  of  the  bladder  evacuated  into  a  glass.  Normally  the 
fluid  is  turbid,  varying  in  density,  and  as  a  rule  contains  no  solid 
elements,  or,  solid  elements  being  present,  they  are  all  of  a  hyaline 
amylacioiis  type.  From  our  investigations  we  would  regard  the 
presence  of  other  solid  elements  as  pathological.  We  have  found 
these  hyaline  bodies  in  the  prostates  of  men  who  have  denied  ever 
having  had  sexual  intercourse,  in  others  having  no  history  of  gonor- 
rhoea, and  in  others  with  chronic  gonorrhoeal  prostatitis,  where 
hyaline  bodies  have  existed  in  conjunction  with  other  solid  elements, 
the  hyaline  bodies  have  remained  after  all  others  had  disappeared. 
In  pathological  conditions  the  solid  elements  vary  from  mere  specks 
to  large  masses  of  irregular  contour  and  often  large,  "skin-like" 
bodies.  All  of  these  varieties  are  pathological,  and  significant  of 
various  degrees  of  prostatitis.  That  the  seminal  vesicles  are  fre- 
quently involved  in  the  process  is  shown  by  the  appearance  in  the 
massaged  urine  of  convoluted  casts  bearing  a  close  resemblance  to 
the  convolutions  of  the  seminal  vesicles.  It  is  only  in  exceptional 
cases  that  the  seminal  vesicles  can  be  accurately  distinguished  from 
the  prostate  by  a  rectal  examination,  but  an  involvement  of  them 
should  be  suspected  by  the  presence  of  these  characteristic  casts  in 
the  massaged  urine  and  the  occurrence  of  blood-tinged  pollutions  and 
ejaculations. 

Microscopically  the  solid  bodies  consist  of  an  inspissated  mucoid 
base,  covered  with  epithelium,  leucocytes,  few  spermatozoa,  and 
bacteria.  They  are  much  less  satisfactory  to  examine  for  gonococci 
than  the  expressed  secretion;  because  of  their  density  and  deep 
staining  properties  a  sharp  definition  is  not  obtained.  Chronic 
parenchymatous  prostatitis  or  interstitial  prostatitis  varies  from  the 
other  forms  in  that  the  entire  gland  is  involved.  It  is  the  least  fre- 
quent of  the  varieties  and  is  only  met  with  after  the  subsidence  of 
very  severe  inflammation  leading  to  abscess  of  the  entire  gland  or  of 
one  lobe.  The  entire  gland  may  have  been  destroyed  and  nothing 
remains  but  a  dense,  fibrous  mass  of  connective  tissue,  or  one  lobe 
alone  may  be  involved.  If,  as  most  frequently  happens,  the  abscess 
ruptures  into  the  urethra,  the  cavity  may  persist  and  drain  by  a 


TREATMENT    OF    CHRONIC    PROSTATITIS. 


159 


listulous  opening  into  the  urethra,  simulating  closely  the  lollicular 
variety.  The  prostate  may  be  enlarged  or  atro- 
phied, the  consistency  is  very  firm  throughout 
or  shows  scattered  areas  of  boggy  consistency. 
In  this  condition  the  gonococci  invade  the  entire 
gland  and  it  is  the  most  serious  variety  to  deal 
with,  a  complete  cure  being  most  difficult  or 
impossible. 

While  it  is  true  that  the  silver  salts  exercise 
a  beneficial  influence  when  employed  in  the 
acute  inflammatory  stage  of  anterior  urethritis, 
and  no  doubt  many  gonococci  are  killed  by 
their  germicidal  properties,  it  is  questionable 
whether  the  improvement  cannot  be  attributed 
more  to  the  frequently  repeated  flushings  of 
the   urethra. 

Treatment  of  Chronic  Prostatitis. — The 
average  case  of  chronic  prostatitis  requires  the 
same  treatment  as  that  of  an  ordinary  chronic 
posterior  urethritis.  It  is  important  that  the 
patient  lead  a  quiet  life  and  abstain  from  alco- 
holic and  sexual  excitement.  Highly  seasoned 
foods  should  not  be  taken,  the  bowels  evacua- 
ted at  least  once  daily  and  violent  exercise  for- 
bidden. The  patient  should  be  assured  that 
his  condition  can  be  cured,  that  he  will  not  be- 
come impotent.  The  local  treatment  consists 
of  instillations  of  nitrate  of  silver  solution  or 
sulphate  of  copper  (i  to  500)  into  the  deep 
urethra  by  means  of  a  soft  rubber  catheter  or 
Keyes-Ultzman  syringe.  Rectal  irrigations  with 
either  hot  or  cold  water  or  a  sitz  bath  are  often 
beneficial.  The  use  of  a  psychrophore  which 
allows  a  constant  flow  of  cold  water,  is  also  effective,  a  cold  sound 
may  also  be  used  in  the  place  of  a  psychrophore  with  the  same  results. 


Fig.  42. — Benique's 

Double    Curve 

Bougie. 


l6o  AFFECTIONS    OF    THE    PROSTATE    GLAND. 

Massage  of  the  prostate  through  the  rectum  is  one  of  the  most 
useful  means  of  inducing  resolution  and  promoting  absorption  of 
the  contained  exudate.  After  the  patient  has  urinated,  instillation 
of  a  few  ounces  of  a  weak  silver  solution  (i  to  3000)  into  the  bladder 
should  be  given  and  then  by  massage  of  the  gland,  the  crypts  and 
follicles  are  emptied  and  the  patient  passes  the  solution  contained 
in  the  bladder,  thus  flushing  the  prostatic  urethra  of  the  expressed 
secretions.  After  all  the  inflammatory  symptoms  have  subsided 
the  use  of  the  Benique  sound  (Fig.  42)  is  valuable  because  of  its 
peculiar  double  curve  which  exercises  a  certain  amount  of  com- 
pression upon  the  gland  and  aids  in  promoting  absorption. 

PROSTATIC  HYPERTROPHY. 

Enlargement  of  the  prostate  gland  known  as  hypertrophy  com- 
monly occurs  in  men  of  advancing  years.  The  increase  in  the  size 
of  the  gland  frequently  assumes  enormous  proportions,  thus  inter- 
fering with  the  function  of  the  bladder,  and  with  the  act  of  micturi- 
tion and  consequently  gives  rise  to  various  disturbances.  The 
principal  lesion  is  said  to  be  inflammatory  in  character,  of  long 
standing  and  involving  the  glandular  structure.  In  these  cases  the 
fibromuscular  stroma  undergoes  secondary  changes,  adding  still 
further  to  the  enlargement. 

Etiology. — The  cause  has  always  been  the  subject  of  much 
discussion.  At  best  the  etiology  is  based  largely  upon  hypotheses. 
Some  authorities  attribute  it  to  venereal  irritation,  while  others 
ascribe  it  to  such  conditions  as  gonorrhoea,  syphilis,  calculus,  and 
stricture. 

Ciechanowski  in  1896  stated  that  the  changes  in  the  stroma  were 
due  to  a  connective  tissue  proliferative  process.  Some  believe 
that  the  original  infection  is  gonorrhoeal,  the  secretion  of  which  is 
accumulated  in  the  narrowed  excretory  duct.  In  other  words  the 
condition  is  essentially  a  chronic  inflammatory  process  or  pros- 
tatitis. This  observation  has  been  confirmed  by  such  authorities 
as  Finger  and  Keyes. 


PATHOLOGY. 


l6l 


Pathology. — It  is  maintained  by  some,  however,  that  the  prin- 
cipal lesion  is  fibromyomatous  in  character,  while  others  claim  that 
the  essential  process  is  distinctly  glandular.  In  the  latter  instance 
the  enlargement  is  mostly  found  in  the  triangular  shaped  posterior 


Fig.  43. — View  of   the  undersurface   of   an   enlarged  prostate — measuring   7x6.5x6 
cm.  and  weighing  145  grammes.     A  catheter  has  been  introduced  through  the  urethra. 
Deaver.) 


median  space  (sometimes  called  the  middle  or  third  lobe)  but  may 
involve  the  lateral  lobes  as  well.  The  gland  being  covered  by  a 
firm  fibrous  capsule  the  organs  often  preserve  a  smooth,  round  or 
oval  shape.     (Fig.  43.)     These  growths  may  predominate  in  the 


II 


1 02  AFFECTIONS    OF    THE    PROSTATE    GLAND. 

glandular  substance  or  upon  the  surface.  In  the  latter  instance  they 
project  toward  the  urethra  or  bladder. 

For  clinical  considerations  the  subject  of  hypertrophy  of  the 
prostate  may  be  summed  up  into  the  following  pathological  con- 
ditions: hypertrophy  of  one  or  both  lobes  only,  hypertrophy  of  the 
median  portion  itself,  hypertrophy  of  the  lateral  lobes  with  bar 
formation,  hypertrophy  of  the  lateral  lobes  and  median  portion  in 
the  shape  of  a  sessile  or  pedunculated  tumor  of  the  middle  lobe. 

Changes  in  the  Urethra. — In  consequence  of  an  enlargement 
of  the  prostate,  there  is  produced  more  or  less  structural  change  in 
the  deep  urethra:  (a)  the  mucous  membrane  becomes  thickened, 
(b)  the  urethra  is  elongated,  (c)  the  normal  curve  is  changed  (Fig. 
43),  (d)  the  lumen  of  the  canal  is  narrowed  and  its  course  irregular, 
(e)  the  dilatability  of  the  prostate  urethra  is  lost  and  the  functions 
of  the  vesical  sphincter  impaired. 

As  a  result  of  these  changes,  the  function  of  the  bladder  is  more 
or  less  interfered  with,  some  of  the  same  urine  passes  into  the 
prostatic  urethra,  while  the  rest  lodges  in  the  post-trigonal  pouch, 
which  the  bladder  is  unable  to  evacuate,  and  therefore  becomes 
residual  urine.  This  pouch  formation  soon  results  in  structural 
changes  in  the  bladder  itself,  the  muscular  fibres  become  much 
hypertrophied  so  that  its  carrying  capacity  is  much  decreased.  In 
many  cases  this  condition  may  be  further  complicated  by  ulceration 
of  the  tissues  overlying  the  enlarged  gland. 

Symptoms. — The  disturbances  to  which  prostatic  hypertrophy 
may  give  rise  depend  upon  the  seat  of  the  enlargement  and  the 
changes  in  the  prostatic  urethra.  In  many  instances  the  symptoms 
are  not  very  marked,  until  the  hypertrophy  is  well  developed.  On 
the  other  hand  the  symptoms  may  develop  quite  rapidly.  One  of 
the  first  symptoms  of  which  the  patient  will  complain  is  difficulty  in 
urination,  which  may  be  either  described  as  a  hesitancy  or  difficulty 
in  starting  the  flow,  or  an  increased  frequency  especially  during  the 
night.  As  the  condition  progresses,  diurnal  frequency  also  occurs. 
Later  it  is  noticed  that  the  size  and  force  of  the  stream  is  decreased, 
with  more  or  less  dribbling  at  the  end  of  the  act.     The  severity  of 


SYMPTOMS. 


163 


this  symptom  varies  according  to  the  condition  of  the  mucous  mem- 
brane of  the  bladder,  the  amount  of  residual  urine,  and  the  degree  of 
stenosis. 

As  a  result  of  the  residual  urine  which  soon  undergoes  decomposi- 
tion the  bladder  and  prostatic  urethra  are  likely  to  become  much  in- 


FiG.  44. — Overgrowth   of  suburethral  portion  of  prostate,  changing  subpubic  curve  of 
urethra  (after  Anger).      (Deaver.) 


flamed,  irritable,  and  painful,  with  a  relative  increased  desire  to  uri- 
nate. The  urine  is  loaded  with  pus  and  mucus  which  is  very  offen- 
sive or  ammoniacal  and  alkaline  in  reaction.  Trabeculations  sometimes 
form,  and  may  contain  deposits  of  phosphatic  concretions  or  calculi. 
In  these  advanced  conditions  the  infective  process  may  ascend  up 
the  ureters  and  involve  the  kidneys,  causing  pyelitis,  pyonephrosis, 


164  AFFECTIONS    OF   THE   PROSTATE   GLAND. 

etc.  The  constitutional  symptoms  which  may  be  complained  of  by 
such  patients  are:  more  or  less  pain  in  the  testis  and  scrotum,  glans 
penis,  perineum,  bladder,  and  rectum.  Hcematuria  may  also  be 
observed  particularly  after  the  passage  of  instruments  or  at  the  end 
of  the  act  of  micturition.  It  is  usually  traceable  to  some  ulcerative 
process. 

Complications. — Retention  of  urine  is  not  an  uncommon 
complication  of  prostatic  hypertrophy  and  occurs  either  as  a  result 
of  congestion  or  spasm.  The  exciting  causes  are,  exposure  to  cold 
and  dampness,  alcoholic  or  sexual  excesses,  constipation  or  opera- 
tions about  the  perineum  and  genital  organs.  It  may  likewise 
result  from  an  impacted  calculus  lodged  near  the  vesical  outlet. 

Dribbling  of  urine,  which  is  seen  in  many  cases,  is  merely  the 
overflow  of  retention  and  when  a  catheter  is  passed  into  the  bladder 
it  will  be  found  to  contain  considerable  residuum.  The  presence 
of  hemorrhoids  is  not  uncommon,  thus  complicating  the  already 
troublesome  symptoms.  In  severe  cases  hernia  or  prolapse  of  the 
rectum  may  result  in  violent  straining  in  an  effort  to  empty  the 
bladder.  Among  the  other  complications  which  frequently  occur 
are  epididymitis  and  orchitis.  A  condition  known  as  catheter  fever, 
and  may  be  caused  by  the  injudicious  use  of  instruments  causing  more 
or  less  traumatism  to  the  bladder  or  urethra.  This  is  marked  by 
chills,  malaise,  and  febrile  disturbances,  but  is  usually  of  short  duration. 
In  some  cases  during  the  course  of  prostatic  hypertrophy,  the  patient 
suffers  from  violent  tenesmus  which  may  be  constant.  The  few 
drops  of  urine  which  he  is  able  to  void  are  scalding  and  as  the  severity 
of  the  lesion  progresses,  health  declines,  he  suffers  from  headaches, 
insomnia,  nervous  irritability,  and  dyspepsia.  Sooner  or  later  he 
develops  urinary  poisoning  as  a  result  of  complicated  kidney  lesions 
and  uraemia.  His  breath  has  a  peculiar  urine-like  odor,  his  tongue 
is  dry  and  coated,  and  unless  surgical  measures  are  resorted  to 
death  ensues. 

Diagnosis. — There  should  be.no  difficulty  in  making  a  diagnosis 
of  prostatic  hypertrophy  after  a  careful  examination  and  noting  the 
patients'  symptoms.     In  obtaining  a  history  the  symptoms  already 


DIAGNOSIS. 


1 6s 


detailed,  when  present  in  a  patient  over  50  years  of  age,  should 
always  suggest  enlargement  of  the  prostate  gland.  This  suspicion 
should  be  confirmed  however  by  urinary,  urethral,  bladder,  and  rectal 
examination.  Digital  examination  of  the  prostate  by  way  of  the 
rectum  is  always  very  important,  in  order  to  ascertain  its  size  and 
consistency  and  to  determine  whether  the  growth  is  fibrous  or  gland- 
ular in  character.  He  should  be  allowed  to  void  his  urine  while 
standing,  observing  the  hesitancy,  the  parabulum  of  the  stream, 


Fig.  45. — Coude  Catheter. 

dribbling,  etc.  The  catheter  is  now  introduced  into  the  urethra  and 
the  remaining  urine  withdrawn,  the  exact  quantity  measured,  and 
then  careful  urinalysis  made,  to  ascertain  whether  there  are  any 
urethral,  bladder,  or  renal  complications.  When  the  bladder  is 
empty,  whUe  the  catheter  is  still  in  situ,  it  is  good  practice  to  irrigate 
with  a  warm  saturated  boric  acid  solution.  The  length  of  the  urethra 
may  be  determined  by  measuring  the  distance  in  which  it  is  necessary 
to  introduce  the  catheter,  before  the  urine  begins  to  flow.  Altera- 
tion in  its  length  is  significant  of  changes  in  the  prostatic  urethra. 


Fig.  46. — Bi-couDE  Catheter. 

If  possible  a  cystoscopic  examination  should  be  made  so  as  to  see 
whether  the  middle  or  lateral  lobe  projects  toward  the  urethra  and 
impinges  upon  the  vesical  outlet.  The  diagnostic  measures  already 
alluded  to  should  be  supplemented  by  an  examination  of  the  urethra 
for  stricture  and  of  the  bladder  for  the  presence  of  a  stone.  This  ex- 
amination should  always  be  conducted  with  the  utmost  gentleness, 
using  a  soft  bougie  a  boule,  olivary  bougies,  coude  (Fig.  45)  or 
bi-coude    (Fig.    46)    catheter   and   the   ordinary   stone   staff.     The 


1 66  AFFECTIONS    OF    THE    PROSTATE    GLAND. 

sensitiveness  of  the  mucous  membrane  and  the  course  and  calibre 
of  the  prostatic  urethra,  may  thus  be  determined  and  any  bar 
obstruction  or  prostatic  projection  at  the  vesical  neck,  or  the  presence 
of  stones  can  usually  be  recognized. 

The  condition  of  the  bladder  walls  can  also  be  ascertained  by 
such  procedure. 

Treatment. — The  treatment  for  relief  of  hypertrophy  of  the 
prostate  is  either  palliative  or  operative,  the  application  of  which 
depends  upon  the  circumstance  of  the  case.  Palliative  measures 
consist  in  the  use  of  instruments  to  "maintain  the  patulency  of  the 
prostatic  urethra,"  by  means  of  a  full  size  steel  or  flexible  rubber 
bougie  and  the  systematic  use  of  a  catheter.  Patients  should  be 
instructed  to  lead  moderate  lives  and  to  eschew  the  use  of  alcoholic 
or  malt  liquors.  Constipation  should  be  guarded  against,  and  they 
must  be  careful  not  to  expose  themselves  to  cold  or  wet.  The 
urine  should  always  be  passed  immediately  when  there  is  any 
desire,  but  if  possible  at  regular  intervals  of  2  or  3  hours  apart. 
They  should  partake  freely  of  bland  waters;  coffee  should  be  al- 
lowed but  once  a  day,  and  highly  seasoned  foods  or  condiments 
should  be  avoided.  Internally  they  may  be  given  urotropin,  boric 
acid  or  salol,  to  prevent  urinary  decomposition.  If  the  urine  is 
excessively  alkaline,  give  dilute  nitro-hydrochloric  or  soda  bicar- 
bonate, etc.  Tonics,  e.g.,  iron,  quinine,  and  strychnine  are  indi- 
cated where  there  is  general  debility.  If  there  is  much  pain  and 
tenesmus,  small  doses  of  opium,  morphine,  and  belladonna  may  be 
prescribed  by  the  mouth  or  rectum.  Prostatic  massage  can  be 
resorted  to  in  some  cases,  but  is  contraindicated  where  there  is  much 
pus  in  the  urine  or  congestion  of  the  prostate.  This  is  often  much 
benefited  by  hot  rectal  irrigations  or  by  the  sitz  bath. 

Catheter  life  consists  in  daily  and  regular  evacuations  of 
the  bladder,  by  means  of  a  catheter,  carried  out  by  the  patient 
himself.  The  catheter  which  he  is  taught  to  use  for  this  purpose 
is  of  soft  rubber  and  he  should  be  impressed  with  the  importance 
of  the  proper  care  and  preparation  of  the  catheter,  necessary  to 
obtain  good  results.     A  small  soft  rubber  instrument  passed  once 


PERINEAL    PROSTATOTOMY.  1 67 

every  24  hours  is  usually  sufficient.  When  the  bladder  is  empty 
it  may  be  irrigated  and  instilled  with  j  to  4  drachms  of  nitrate  of 
silver  solution  (i  to  4000).  If  the  patient  is  disturbed  very  often 
at  night  a  catheter  may  be  passed  and  retained,  and  attached  to  a 
soft  rubber  tube  which  empties  into  a  receptacle  at  the  side  of  the 
bed. 

Operative  treatment. — When  palliative  treatment  ceases  to  be 
of  benefit  or  give  the  patient  any  relief,  and  the  symptoms  of  the 
disease  become  more  marked,  operation  is  justifiable.  It  should 
only  be  resorted  to  where  there  is  an  increased  amount  of  obstruc- 
tion; when  the  passage  of  the  catheter  is  accompanied  by  much 
pain  or  hemorrhage,  and  in  cases  where  there  is  complete  retention, 
also  in  severe  cystitis  and  conditions  in  which  the  amount  of  residual 
urine  is  increasing.  A  gland  palpable  by  the  rectum,  and  rising 
not  far  from  the  sphincter  muscle,  can  best  be  attacked  from  below, 
but  when  higher  up  and  projecting  into  the  bladder,  it  should  be 
operated  on  from  above.  When  the  enlargement  is  soft  and  com- 
posed of  small  lobes,  operate  from  below.  If  the  condition  is  com- 
plicated by  the  presence  of  a  large  calculus,  work  from  above. 
The  preservation  of  sexual  power  is  important,  therefore,  injury 
to  the  ejaculatory  ducts  should  be  avoided  if  possible.  The  follow- 
ing operations  each  have  their  special  indications  and  are  as  follows: 

Perineal  prostatotomy  is  a  more  or  less  blind  operation, 
as  the  surgeon  must  work  through  a  small  wound.  The  patient 
is  placed  in  the  lithotomy  position,  a  tunnelled  sound  is  passed  and 
steadied  by  an  assistant  who  at  the  same  time  also  holds  the  scro- 
tum out  of  the  way.  The  urethra  is  now  opened  at  the  apex  of  the 
prostate  over  the  convexity  of  the  instrument.  The  surgeon  then 
dilates  the  prostatic  urethra  with  his  forefinger,  and  any  obstruction 
that  is  met  is  incised  by  a  blunt  bistoury,  and  a  soft  rubber  perineal 
tube  or  large  catheter  inserted  for  drainage.  The  danger  of  hemor- 
rhage is  always  imminent  in  this  operation.  It — the  operation — 
is  especially  indicated  where  the  growth  projects  toward  the 
prostatic  urethra  and  obstructs  the  vesical  orifice. 

Urethral  prostatotomy  is  rarely  performed  of  late  years.     It 


1 68  AFFECTIONS    OF    THE   PROSTATE   GLAND. 

simply  consists  of  dividing  the  obstruction  in  the  prostatic  urethra, 
with  the  prostatome  passed  by  the  way  of  the  urethra. 

The  choice  of  methods  of  operating  upon  hypertrophied  prostate, 
depends  largely  upon  the  judgment  of  the  surgeon.  The  3  prin- 
cipal methods  are  the  perineal  and  suprapubic  prostatectomy  and 
galvanocaustic  prostatotomy  (Bottini's),  which  is  an  intra- vesicle 
operation,  each  of  which  hold  a  distinct  place  in  prostatic  surgery. 

Perineal  prostatectomy  consists  of  a  partial  or  complete  ex- 
tirpation of  the  gland  through  a  perineal  incision.  This  operation 
as  modified  by  Alexander,  consists  of  making  a  small  suprapubic 
incision.  The  patient  is  then  placed  in  the  lithotomy  position,  a 
tunnelled  sound  passed,  and  the  urethra  opened  on  the  convexity  of 
the  instrument,  the  sound  is  then  withdrawn  and  the  gland  pressed 
down  in  the  perineal  wound,  through  the  suprapubic  opening.  The 
capsule  of  the  prostate  is  opened  at  its  apex  and  the  gland  enucleated, 
first  removing  each  of  the  lateral  lobes  and  the  median  portion. 
The  bladder  is  then  drained  above  and  below  through  both  inci- 
sions. This  operation  may  be  done  without  the  suprapubic  cys- 
totomy by  which  good  results  are  often  obtained.  H.  H.  Young 
makes  an  inverted  Y  cutaneous  incision  into  the  perineum,  the  re- 
mainder of  the  operation  being  done  by  blunt  dissection,  with  the 
exception  of  the  central  tendon  and  recto-urethralis  muscle.  The 
urethra  is  then  entered,  the  mucous  membrane  engaged  with  for- 
ceps, and  the  tractor  introduced,  in  bringing  the  prostate  in  the 
wound.  Incision  is  made  into  the  capsule  over  each  lateral  lobe 
and  the  gland  removed  with  blunt  dissection  and  the  fingers.  A 
drainage  tube  is  sutured  at  the  apex  of  the  skin  wound.  The 
patient  is  given  plenty  of  water  to  drink.  Subsequent  instrumen- 
tation is  avoided,  and  the  patient  is  got  out  of  bed  as  soon  as 
possible. 

Suprapubic  prostatectomy  is  a  favorite  operation  among  many 
surgeons  who  claim  better  results  from  this  operation  than  any 
other  method.  .  The  advantages  claimed  are,  that  the  growth  can 
be  seen,  the  access  to  the  gland  is  better,  and  therefore  hemorrhage 
more  easily  controlled  and  calculi  easily  removed,  if  the  occasion 


freyer's  operation.  169 

presents  itself.  The  operation  is  as  follows:  suprapubic  cys- 
totomy is  performed  and  the  bladder  sutured  to  the  parietal  incision, 
the  prostate  is  then  inspected  and  the  projecting  over-growth 
removed.  Incisions  are  made  into  the  mucous  membrane  of  the 
bladder  and  the  portions  of  the  gland  enucleated  by  blunt  dissection. 
The  hemorrhage  can  then  be  controlled  by  hot  irrigations  and 
packing  and  a  drainage  tube  inserted  through  the  suprapubic 
opening. 

Freyer's  operation  is  advocated,  especially  among  surgeons 
who  prefer  the  suprapubic  route.  It  is  not  indicated  in  the 
first  stages  of  prostate  hypertrophy,  except  in  cases  where  there  is  a 
suspicion  or  evidence  of  malignancy.  The  patient  should  be  in  the 
best  possible  physical  condition,  and  when  there  is  any  evidence  of 
sepsis,  a  preliminary  suprapubic  incision  should  be  employed,  after 
which  careful  drainage  may  remove  the  septic  condition  and  thus 
diminish  the  dangers  of  the  subsequent  operation.  Internally 
urinary  antiseptics  should  be  administered.  After  an  interval  of 
from  four  to  eight  weeks  the  second  operation  is  performed.  The 
patient  is  placed  in  a  moderate  degree  of  Trendelenburg  posture. 
The  bladder  is  irrigated  with  either  mercury  oxy cyanide  i :  2000, 
care  being  taken  that  no  fluid  remains  in  the  bladder.  The  latter 
is  not  filled  with  air  until  after  the  abdominal  muscles  have  been 
dixided  so  that  the  operator  can  regulate  the  amount  of  distention 
under  the  guidance  of  the  eye.  The  bladder  is  exposed  by  a  supra- 
pubic incision.  Two  silk  sutures  are  then  fastened  in  the  outer 
coats  of  the  bladder,  one  on  either  side  and  held  by  an  assistant  with 
clamps.  The  opening  in  the  bladder  is  surrounded  with  sterile 
gauze  and  the  incision  is  made  between  the  sutures — the  cut  being 
longitudinal  and  high  up  toward  the  apex  of  the  organ.  Any 
remaining  fluid  in  the  bladder  should  be  sponged  out  thoroughly. 
The  catheter  acts  as  a  guide  to  the  urethral  orifice  and  prostatic 
lobes.  When  the  gland  is  located  the  mucous  membrane  covering 
one  lobe  is  incised,  the  finger  introduced  and  enucleation  begun. 
With  one  or  two  fingers  of  an  assistant  or  the  operator's  other  hand 
in  the  rectum  the  prostate  is  pushed  up  toward  the  enucleating 


lyo  AFFECTIONS    OF    THE    PROSTATE    GLAND. 

linger.  ^Sometimes  both  lobes  may  be  enucleated  through  the  one 
incision  in  the  mucus,  and  in  other  instances  a  second  incision  will 
have  to  be  made  over  the  other  lobe.  Usually  the  ejaculatory  ducts 
and  prostatic  urethra  will  be  divided.  After  the  enucleation  is  com- 
pleted the  cavity  formed  by  the  removal  of  the  prostate  is  irrigated 
with  hot  boric  acid  or  saline  solution.  If  hemorrhage  persists  pack 
with  iodoform  gauze  or  gauze  saturated  with  adrenalin  and  suture 
the  overlying  mucous  membrane  leaving  an  end  through  the  abdom- 
inal opening.  During  the  packing  have  an  assistant  make  counter- 
pressure  with  his  fingers  in  the  rectum.  The  packing  may  be  re- 
moved in  three  or  four  days.  As  regards  drainage,  Freyer's  tube 
carefully  inserted  for  a  distance  of  about  an  inch  in  the  bladder,  care 
being  taken  the  end  does  not  come  in  contact  with  the  mucous  mem- 
brane of  the  floor  of  the  bladder.  A  rubber  tube  is  then  attached 
so  as  to  carry  the  urine  to  a  receptacle  placed  between  the  patient's 
legs.  The  outer  incision  may  be  partially  closed  or  allowed  to  heal 
by  granulation  and  packed  with  iodoform  gauze  so  as  to  draw  the 
cavity  of  Retzius.  These  should  be  changed  daily  and  the  patient 
allowed  to  get  up  as  soon  as  possible.  The  tube  may  be  removed  on 
the  fifth  day  and  a  smaller  tube  introduced  which  is  removed  after 
two  weeks.  Irrigations  are  not  necessary  (according  to  Steiner 
who  has  had  a  large  experience  with  Freyer's  method)  so  long  as  the 
drainage  tube  is  kept  free  from  clots. 

Bottini's  Operation. — The  indications  for  this  operation  are 
cases  in  which  there  is  a  middle  lobe  projection  with  the  formation 
of  an  obstructing  bar,  and  where  there  are  healthy  bladder  walls. 
These  facts  should  be  ascertained  by  the  use  of  the  cystoscopy 
The  patient  is  placed  flat  on  his  back,  the  bladder  and  urethra 
irrigated  with  a  warm  normal  salt  solution,  allowing  a  few  ounces 
to  remain  in  the  bladder  (or  air  may  be  used  to  distend  the 
bladder  walls).  General  or  local  anaesthesia  may  be  used  in  per- 
forming this  operation. 

The  instruments  (Fig.  47)  should  always  be  first  tested  and  the 
exact  amount  of  current  ascertained  to  bring  the  blade  to  a  white 
heat.     Assurance   being  obtained   that  the   apparatus  is  working 


BOTTINl'S    OPERATION. 


171 


Fig    47. — The  Bottini  galvano-cautery.     Young's  modification  of  the  Bottini  incisor 

with  blades  of  various  sizes. 


172 


AFFECTIONS    OF    THE    PROSTATE    GLAND. 


satisfactorily,  the  instrument  is  then  passed  into  the  bladder  and  its 
beak  turned  down  into  the  post-prostatic  pouch  and  then  drawn 
(as  shown  in  Fig.  48)  forward  until  it  engages  the  obstruction.     The 


Fig.   48. — The  Bottini  incisor  in  use.      (After  Socin  and  Burc'khardt.) 

shaft  is  now  kept  cool  by  means  of  a  constant  stream  of  cold  water 
and  the  current  turned  on.  After  a  few  seconds,  the  exact  time 
of  which  had  been  previously  obtained,  in  order  to  bring  it  to  white 
heat,  the  wheel  at  the  end  of  the  instrument  is  slowly  turned  for  the 


RETENTION  OF  URINE.  1 73 

distance  necessary  to  traverse  the  obstruction.  The  incision  thus 
made,  the  wheel  is  reversed  and  the  current  immediately  turned  off 
by  an  assistant  or  preferably  an  electrician,  and  the  blade  returned 
to  the  groove  in  the  shank.  The  first  incision  having  been  made 
on  the  median  line,  the  instrument  is  slightly  turned  upward  toward 
the  lateral  lobes  which  are  incised  in  the  manner  thus  described. 
The  hemorrhage  following  this  operation  is  comparatively  slight  and 
in  proper  cases  renders  the  method,  therefore,  preferable  to  any 
other.  The  untoward  complications  which  may  follow  it  are: 
abscess  of  the  prostate,  epididymitis,  and  very  rarely  sepsis.  The 
after  treatment  simply  consists  of  keeping  the  patient  in  bed,  and 
allowing  him  to  urinate  alone,  but  if  necessary  he  may  be  catheter- 
ized.  In  cases  of  advanced  carcinoma  Bottini's  operation  is  pre- 
ferred as  a  palliative  operation. 

Orchidectomy  and  vasectomy  have  rightly  been  condemned, 
as  both  methods  are  regarded  as  useless. 

Regarding  the  use  of  the  D^Arsenval  current  in  the  treatment  of 
chronic  prostatitis,  and  prostatic  hypertrophy,  we  are  still  in  the 
experimental  stage,  further  work  being  required  to  determine  its 
value. 

Treatment  of  Retention  of  Urine  from  Hypertrophy  of  the 
Prostate. — Should  retention  at  any  time  occur,  immediate  relief 
is  of  course  indicated.  It  must  be  borne  in  mind  that  the  obstruc- 
tion to  be  overcome  is  the  pressure  of  the  swollen  lateral  lobes  and 
the  upward  and  often  irregular  projection  of  the  isthmus  of  the 
gland.  (Fig.  44.)  The  urethra  is  tortuous  and  elongated  perhaps. 
The  instruments  required  are  one  for  lateral  enlargement  of  elon- 
gated.or  tortuous  urethra,  and  one  with  a  soft  and  pliant  extremity. 
The  Nelaton  catheter,  so  stiffened  as  to  give  a  firm  shank,  with 
flexible  point,  will  answer. .  For  the  projection  of  the  third  lobe 
an  upturned  tip  with  a  soft  and  pliant  beak  is  suitable.  The  Mercier 
elbowed  catheter,  coude  or  bicoude  catheter  possesses  these 
qualities;  and  for  practical  purposes,  if  sufficiently  stiff  in  shank,  or 
stiffened  by  the  insertion  of  a  whalebone,  or  filiform,  is  well  suited 
for  catheterization  in  all  cases  of  senile  prostatic  enlargement,  is 


174  AFFECTIONS    OF    THE   PROSTATE    GLAND. 

long  enough  to  reach  the  bladder  and  sufficiently  pliant  (especially 
if  the  lower  end  be  first  immersed  in  warm  water)  to  follow  the 
tortuous  urethra,  and  its  elbowed  tip  will  easily  ride  over  the  pro- 
jecting isthmus  without  catching  or  producing  unnecessary  pain. 

Before  beginning .  the  manipulation,  it  is  well  to  inject  into  the 
orifice  of  the  urethra  a  little  olive  oil.  Then  having  slightly  stretched 
the  urethra,  and  keeping  it  in  the  median  line,  insert  into  the  meatus 
the  beak  of  the  Mercier  catheter,  tip  upward.  Then  taking  care 
not  to  engage  the  tip  in  the  lacuna  magna,  press  down  the  instrument 
until  its  point  can  be  felt  at  the  enlarged  prostate.  Then  firmly 
and  gently  press  it  onward.  As  the  beak  passes  between  the 
lateral  lobes  their  pressure  can  be  felt,  and  when  it  mounts  over  the 
isthmus,  that  also  can  be  detected.  The  bladder  cavity  is  thus 
reached,  and  the  evacuation  accomplished,  a  few  drachms  of  urine 
being  left  to  prevent  any  after  shock.  The  soft-rubber  Nelaton  or 
coude  catheter  is  used  in  a  precisely  similar  manner,  its  upper 
portion  having  been  stiffened  by  the  insertion  of  a  whalebone  or 
filiform.  As  described,  the  insertion  of  a  catheter  in  this  form  of 
retention  is  not  productive  of  much  pain. 

The  overcurved  long  English  prostatic  catheter  has  been  strongly 
advised  by  Sir  Henry  Thompson.  This  when  softened  by  warm 
water  may  undoubtedly  be  passed  in  many  instances.  The  Mercier 
and  Nelaton  catheters,  however,  if  used  as  described  are  sufficient 
to  reach  satisfactory  results.  The  soft  instruments  are  better  fitted 
for  introduction  through  an  enlarged  and  tender  prostate  than 
metal  instruments. 

Tuberculosis  of  the  prostate  frequently  develops  secondarily, 
in  cases  of  tuberculosis  of  the  genito-urinary  tract.  Primary  tuber- 
cular infection  of  the  prostate  is  rare,  and  is  usually  seen  in  early 
life.  The  course  may  be  gradual  or  rapid.  The  principal  symp- 
toms are  pain,  particularly  on  urination,  and  a  profuse  mucopuru- 
lent discharge  increased  on  defecation.  On  rectal  examination  the 
nodules  may  be  distinctly  felt,  in  most  cases,  unless  the  urethral 
part  of  the  prostate  is  the  seat  of  the  disease  itself.  Massage  of  the 
prostate  and  the  expressed  secretions  in  the  urine  following  should 


PROSTATIC    CALCULI.  1 75 

1)6  examined  microscopically.      This  procedure  will  in  many  in- 
stances corroborate  the  diagnosis. 

Treatment. — The  condition  may  be  much  benefited  by  warm 
irrigations  of  the  bladder  and  rectum,  followed  by  instillations  of 
iodoform  in  sweet-oil  (lo  per  cent.),  or  creosote  in  liquid  vaseline 
(2  per  cent.).  These  measures  are  especially  valuable  even  where 
ulcerations  of  the  urethra  have  taken  place.  Change  of  climate 
may  also  be  advised  in  conjunction  with  the  local  treatment. 
Tubercular  abscess  of  the  prostate  should  be  drained  through  an 
incision  in  the  perineum,  just  in  front  of  the  rectum.  After  the 
pus  is  evacuated,  pack  with  iodoform  gauze. 

Prostatic  calculi  are  sometimes  deposited  in  the  follicles  of  the 
prostate,  where  they  often  become  encysted.  They  consist  largely 
of  phosphate  of  lime. 

Symptoms. — Such  deposits  are  marked  by  irritability  of  the 
posterior  urethra,  pain  in  the  deep  urethra,  extending  down  toward 
the  rectum.  In  some  cases  they  can  be  detected  by  digital  examina- 
tion of  the  prostate  by  way  of  the  rectum.  The  treatment  is  neces- 
sarily surgical,  and  simply  consists  of  making  a  perineal  incision, 
through  which  the  calculi  are  extricated. 

Malignant  Growths. — Carcinoma  is  more  frequent  than 
sarcoma,  both  of  which  are  comparatively  rare.  Albarran  and 
H.  H.  Young  claim  that  about  ten  per  cent,  of  all  prostatic  enlarge- 
ments are  carcinomatous. 

The  symptoms  in  the  beginning  are  practically  those  of  benign 
hypertrophy.  Suddenly  the  patient  is  attacked  with  severe  pains 
which  may  be  constant  or  intermittent,  radiating  in  all  directions. 
The  prostate  will  be  tender  to  touch,  and  when  this  is  seen  in  men 
past  50  years  of  age,  should  always  be  viewed  with  suspicion, 
especially  if  there  be  marked  induration  with  the  enlargement  of 
the  gland,  nodular  in  character,  and  where  the  cystoscope  shows 
but  little  intra-vesicular  prostatic  outgrov/th.  The  urination  is 
increased  in  frequency  day  and  night  and  soon  the  patient  suffers 
from  constant  pain  and  tenesmus.  This  condition  in  a  short  time 
is  complicated  with  cystitis,  sometimes  with  retention,  and  kidney 


176  AFFECTIONS    OF    THE    PROSTATE    GLAND. 

lesions,  the  result  of  ascending  infection  and  urinary  obstruction. 
Hemorrhages  may  follow,  occurring  independently  of  any  effort  to 
empty  the  bladder.  Involvement  of  the  pelvic  glands  occurs  late, 
and  the  patient's  general  health  declines. 

Treatment. — Young's  method  in  dealing  with  these  cases, 
especially  where  the  diagnosis  of  malignancy  is  doubtful,  is  as  fol- 
lows: The  posterior  surface  of  the  prostate  is  exposed,  as  for  an 
ordinary  prostatectomy,  longitudinal  incision  made  on  each  side  of 
the  urethra,  and  a  piece  of  tissue  excised  for  frozen  sections  and 
examined  microscopically.  This  he  states  can  be  done  in  six 
minutes.  If  the  disease  is  malignant,  the  radical  operation  is  per- 
formed in  which  he  removes  the  entire  prostate,  seminal  vesicles 
vas  deferentia,  and  most  of  the  trigonum. 

Young  describes  his  operation  practically  as  follows: 

The  prostate  is  exposed  as  in  the  operation  of  perineal  prosta- 
tectomy. The  handle  of  the  retractor  is  then  depressed  so  as  to 
expose  the  membranous  urethra,  which  is  then  divided  transversely. 
By  further  depressing  the  handle  of  the  tractor  the  pubo-prostatic 
ligament  is  exposed,  and  is  divided  with  scissors,  thus  completely 
severing  the  prostate  from  all  important  attachments  except  pos- 
teriorly.    The  lateral  attachments  are  then  separated  by  the  fingers. 

The  posterior  surface  of  the  seminal  vesicles  is  then  freed  by 
blunt  dissection,  the  now  mobile  prostate  being  well  out  of  the 
wound.  In  exposing  the  posterior  surface  of  the  vesicles  care  must 
be  taken  not  to  break  through  the  fascia  of  Denonvilliers,  which 
covers  the  posterior  surface  of  the  prostate  and  seminal  vesicles,  and 
which  undoubtedly  forms  an  important  barrier  to  the  backward 
growth  of  the  disease. 

The  next  step  is  to  expose  the  anterior  surface  of  the  bladder  by 
still  further  depressing  the  tractor  and  making  strong  traction. 
The  bladder  is  then  incised  at  a  point  in  the  middle  line  about  i  cm. 
behind  the  prostato-vesicle  junction.  The  dissection  is  then  con- 
tinued on  each  side  with  scissors  until  the  trigone  is  exposed.  The 
trigone  is  then  incised  transversely  about  i  cm.  in  front  of  the 
ureteral  orifices. 


MALIGNANT    GROWTHS.  1 77 

While  still  making  traction  upon  the  prostate,  the  base  of  the 
bladder  is  pushed  upward  so  as  to  expose  the  anterior  surface  of  the 
seminal  vesicles  and  the  adjacent  vasa  deferentia,  all  of  which  are 
carefully  freed  by  blunt  dissection  with  the  finger  as  high  up  as 
possible,  so  as  to  remove  with  the  vesicles  the  circumjacent  fat  and 
areolar  tissues  on  account  of  the  lymphatics  which  they  contain. 
The  vasa  deferentia  are  divided  as  high  up  as' possible,  care  being 
taken  to  see  that  the  ureters  are  not  cut  with  them. 

An  anastomosis  is  then  made  between  the  bladder  and  mem- 
branous urethra  and  the  remainder  of  the  vesical  wound  closed. 
The  first  suture  is  placed  by  inserting  the  needle  into  the  triangular 
ligament  above  the  urethra  and  out  through  the  anterior  wall  of 
the  bladder  in  the  median  line,  from  within  out,  care  being  taken  to 
include  only  the  submucosa  and  muscle.  When  this  suture  is  tied, 
the  median  line  of  the  anterior  wall  of  the  bladder  is  drawn  to  meet 
the  urethra,  the  knot  outside,  and  the  thread  left  long. 

Lateral  sutures,  similarly  placed  (including  the  periurethal 
muscular  structures  below),  and  two  posterior  sutures  complete  the 
anastomosis  of  the  membranous  urethra  with  a  small  ring  into 
which  the  anterior  portion  of  the  margin  of  the  vesical  would  have 
been  fashioned  by  the  tying  of  the  sutures. 


12 


CHAPTER  IX. 

SURGICAL  AFFECTIONS  OF  THE  KIDNEY. 

Surgical  Anatomy. — The  kidneys  are  situated  on  the  posterior 
wall  of  the  abdomen,  behind  the  peritoneum,  and  extend  from  the 
nth  rib  to  the  3rd  lumbar  vertebra  or  almost  to  the  crest  of  the 
ilium.  The  left  kidney  is  a  trifle  higher  than  the  right  on  its  upper 
surface,  but  the  lower  ends  are  the  same.  The  posterior  surfaces 
are  in  close  relation  with  the  diaphragm  above.  The  front  of  the 
right  kidney  lies  in  close  contact  with  the  duodenum  and  ascending 
colon.  It  is  also  close  to  the  ascending  vena  cava.  In  front  of  the 
left  kidney  are  the  descending  colon,  the  spleen,  stomach,  and  tail 
of  the  pancreas.  The  internal  border  of  the  psoas  muscle,  imbed- 
ded in  a  layer  of  fat  and  enveloped  by  a  fatty  capsule  which  in  con- 
junction with  the  renal  artery  and  vein  and  the  ureter  maintains  the 
position  of  the  organ.  The  relation  of  the  kidneys  to  the  anterior 
abdominal  wall  is  as  follows:  The  upper  pole  of  the  kidney  with 
its  suprarenal  capsule  is  in  the  epigastric  region.  The  lower  pole 
corresponds  to  a  line  drawn  from  the  middle  of  Poupart's  ligament 
to  the  cartilage  of  the  8th  rib,  at  the  level  of  the  umbilicus.  The 
kidney  is  a  slightly  movable  organ. 

PERINEPHRITIS. 

Inflammation  of  the  cellular  tissues  surrounding  the  kidneys 
which  in  most  instances  undergoes  suppuration  and  abscess 
formation,  hence  the  term  perinephritic  abscess.  Perinephritis 
may  occur  secondarily  by  extension  from  suppurative  processes  in 
the  abdominal  viscera,  pelvis,  bones,  lung,  and  pleura,  also  from 
pyelitis,  pyelonephritis,  and  pyonephrosis,  etc.  The  primary  form  is 
much  less  common  and  is  that  form  in  which  suppuration  begins  in 

178 


PYONEPHROSIS.  1 79 

the  postrenal  connective  tissue  and  is  usually  caused  by  traumatism. 
The  abscess  cavity  may  rupture  into  the  colon  or  stomach  and  into 
the  pleural  cavity  or  within  the  sheath  of  the  psoas  muscle  and 
burrow  toward  the  femoral  or  gluteal  regions  forming  urinary  or 
renal  fistulas. 

Symptoms. — The  perirenal  lesion  is  usually  obscure  owing 
to  the  fact  that  it  is  most  often  secondary  to  disease  elsewhere, 
hence  the  symptoms  will  center  in  other  affections  until  the  peri- 
nephritis is  sufficiently  advanced  to  give  rise  to  distinct  symptoms. 
When  the  lesion  is  traumatic  the  condition  as  a  rule  is  easily  recog- 
nized. Deep  seated  pain  in  the  loins  may  develop  insidiously  or 
suddenly.  In  thin  patients  bimanual  palpation  over  the  abdomen 
and  loin  of  the  affected  side  will  furnish  some  information  or  at 
least  suspicion  of  perinephritis.  The  pain  soon  extends  into  the 
legs  and  is  aggravated  by  motion  and  the  condition  may  become  so 
severe  that  the  leg  is  flexed  upon  the  abdomen  and  the  body  bent 
forward.  This  is  accompanied  by  more  or  less  fever,  chills,  rigors, 
and  vomiting.  Fluctuation  may  be  felt  in  the  lumbar  region  in  some 
cases.     This  is  often  attended  with  swelling  and  discoloration. 

Treatment. — The  diagnosis  being  firmly  established  the  patient 
should  receive  treatment  identical  with  that  directed  for  any  of  the 
suppurative  diseases  of  the  kidney.  When  there  is  abscess  forma- 
tion, the  pus  must  be  evacuated  by  a  free  lumbar  incision  and  the 
cavity  and  surrounding  tissues  flushed  with  hot  normal  saline 
solution,  drainage  tubes  inserted,  and  lightly  packed  with  gauze. 

PYONEPHROSIS. 

The  pelvis  and  cahces  of  the  kidney  may  become  dilated  as  a 
result  of  some  ureteral  obstruction,  probably  due  to  pyeHtis  and 
pyelonephritis.  These  will  be  found  to  contain  pus,  urinary 
salts,  tuberculous  material,  blood,  and  tissue  detritus.  This  forms  a 
fluctuating  mass  which  sooner  or  later  may  assume  considerable 
size  depending  on  the  patulency  of  the  ureter.  In  time  the  process 
involves   the    entire    kidney   structure   which    becomes  one  large 


l8o  SURGICAL  AFFECTIONS    OF   THE    KIDNEY. 

abscess  cavity  filled  with  pus.  Pyonephrosis  may  attack  one  or  both 
kidneys. 

Symptoms. — These  are  practically  the  same  as  those  observed 
in  pyelitis  and  pyelonephritis,  but  usually  much  more  pronounced 
(see  pyelitis). 

Diagnosis. — The  tumor  is  as  a  rule  large,  fluctuating,  and 
extremely  painful.  The  systemic  reaction  is  marked  by  high  fever 
and  pyuria.  The  principal  conditions  with  which  it  may  be  con- 
founded in  making  a  diagnosis  are:  fecal  impaction,  abscess  of  the 
spleen  and  gall  bladder,  stone  in  the  gall  bladder,  abscess  of  the 
liver,  renal  carcinoma,  and  tubercular  diseases  of  the  kidney. 

Prognosis  is  more  favorable  when  the  condition  is  unilateral. 
It  may  last  for  years  without  affecting  the  general  health  of  the 
patient,  but  such  instances  are  rare. 

Treatment. — If  possible  the  obstruction  of  the  ureter  should  be 
removed.  This  may,  sometimes,  be  accomplished  either  by  the 
use  of  the  ureteral  catheter,  or  having  the  patient  drink  freely  of 
water  so  as  to  induce  active  diuresis.  If  these  measures  fail  the 
kidney  may  be  aspirated  or  nephrotomy  can  be  performed  and  the 
kidney  drained.  The  operation  of  nephrectomy  is  only  indicated  in 
extreme  cases  and  only  where  the  opposite  kidney  is  sound. 

HYDRONEPHOSIS. 

Any  occlusion  of  the  urethra,  bladder,  or  ureter,  may  occasion 
a  damming  of  the  urine  in  the  pelvis  of  the  kidney  with  consequent 
dilatation  of  both  pelvis  and  calices.  The  distention  thus  caused 
may  result  in  atrophy  of  the  kidney  and  chronic  nephritis.  One  or 
both  organs  may  be  involved  and  the  tumor  may  assume  an  enor- 
mous size.  This  condition  is  frequently  found  in  young  children 
(congenital  hydronephrosis,  due  to  mal-development  of  the  ureters, 
etc.).  The  acquired  form  is  commonly  caused  by  movable  kidney, 
kinking  of  the  ureter  from  pressure  by  tumors,  etc.,  and  ureteral 
calculi. 

Symptoms. — These  depend  on  the  degree  of  distention,  but  are 


RENAL    CALCULI.  l8l 

usually  ushered  in  by  dull  pain  in  the  loins  which  becomes  intensified 
as  the  condition  advances.  This  is  not  accompanied  by  fever  unless 
complicated  by  infection.  The  development  may  be  slow  or  rapid. 
The  swelling  may  be  temporarily  lessened  by  the  fluid  escaping 
through  the  ureter.  When  caused  by  ureteral  calculi,  severe  colic 
and  hematuria  are  usually  present. 

Diagnosis. — Hydronephrosis  may  be  mistaken  for  ovarian  cysts. 
The  presence  of  pain  and  discomfort  in  the  loins  with  a  cystic  tumor 
in  the  flank  are  its  chief  diagnostic  symptoms.  To  be  more  precise, 
however,  catheterization  of  the  ureters  should  be  performed  and  the 
secretions  examined  microscopically. 

Prognosis. — In  unilateral  hydronephrosis  the  prognosis  is  good 
as  a  rule,  while  bilateral  cases  may  cause  death.  Surgical  inter- 
vention therefore  should  not  be  delayed  in  serious  cases. 

Treatment. — When  due  to  obstruction  or  kinkmg  of  the  ureters, 
an  operation  should  be  immediately  performed  to  relieve  the  condi- 
tion. Impacted  ureteral  calculi  can  be  sometimes  dislodged  by 
means  of  the  ureteral  catheter  and  the  hydronephrosis  drained. 
Aspiration  or  nephrectomy  are  indicated  where  these  methods  fail. 
Nephrectomy  should  be  resorted  to  after  ascertaining  the  condition 
of  the  opposite  kidney. 

RENAL  CALCULI. 

Stone  in  the  kidney  may  consist  of  one  or  more  salts  deposited 
around  nucleus  depending  upon  the  state  of  the  urine  during  the 
disease  process  of  the  kidney,  or  of  its  pelvis.  They  may  be  com- 
posed of  urates,  oxalates,  or  phosphates,  while  the  nucleus  usually 
consists  of  a  blood  clot,  tissue  detritus,  mucus,  and  epithelium  held 
together  by  an  albuminoid  substance,  which  is  present  when  the 
urinary  tract  is  diseased.  The  pelvis  or  the  renal  parenchyma  may 
be  the  seat  of  the  stone.  They  may  be  single  or  multiple,  varying 
in  their  shape,  size,  and  consistency  and  are  said  to  occur  more 
frequently  in  men  than  in  women.  A  sedentary  life  is  probably 
conducive  to  stone  formation. 


l82  SURGICAL  AFFECTIONS    OF    THE    KIDNEY. 

Symptoms. — These  depend  on  the  amount  of  ureteral  obstruction 
and  the  inflammation  it  produces  as  a  foreign  body  in  the  kidney. 
Years  may  elapse  in  some  cases  before  its  presence  will  cause  any 
discomfort,  though  in  most  instances  there  is  intense  pain  occurring 
at  brief  intervals.  These  attacks  are  often  spoken  of  as  renal  colic. 
The  pain  is  in  the  lumbar  region  and  deep  seated.  Instead  of  being 
confined  to  this  one  area  it  may  extend  into  the  scrotum  causing 
retraction  of  the  testicle.  Increased  frequency  of  a  painful  micturi- 
tion, vesical  and  rectal  tenesmus,  are  symptoms  not  uncommonly 
met  with  in  cases  of  renal  calculi.  In  rare  cases  even  suppression  of 
urine  occurs.  Haematuria  is  another  very  important  symptom  and 
is  usually  characteristic  in  that  it  often  follows  a  sharp  attack  of 
pain,  and  seldom  lasts  long.  Small  calcuH  or  fragments  may  be 
passed  with  the  urine  during  or  after  severe  colic.  Pyuria  is  only 
present  where  there  is  infection  of  the  kidney  tissue.  Nausea  and 
vomiting  also  accompany  these  symptoms.  In  conclusion  the 
symptom  complex  of  renal  calculi  may  for  convenience  be  summed 
up  as  follows: 

Attacks  of  renal  colic. 

Deep  seated  lumbar  pain. 

Ephemeral  haematuria. 

Pyuria  in  infected  cases. 

Frequent  and  painful  urination. 

Gastr^-intestinal  disturbances. 

Passage  of  fragments  of  calculi. 

Diagnosis. — Chemic  and  microscopic  examination  of  the  urine, 
careful  review  of  the  patient's  history  of  previous  attacks,  the  diath- 
esis, etc.,  should  be  made.  The  kidney  on  palpation  is  tender  and 
tense.  An  X-ray  examination  should  always  be  made  and  the 
evidence  obtained  is  nearly  always  conclusive  unless  the  patient  is 
very  large  and  fat,  in  which  instance  the  stone  may  not  show.  (Fig. 
49.)  Lumbar  incision  and  palpation  with  the  finger  and  exploring 
by  a  needle  has  also  been  practised,  but  this  is  rarely  necessary  since 
the  advent  of  the  X-ray. 

Treatment. — The  palliative  measure  consists  in  correcting  the 


TUMORS. 


183 


condition  of  the  urine  where  the  patient  is  passing  sand  and  gravel. 
In  these  cases  the  kidneys  should  be  flushed  by  allowing  the  patient 
an  abundance  of  drinking  water.  Any  severe  pain  may  be  temporar- 
ily relieved  by  the  use  of  morphia,  hot  baths,  hot  applications  over 
the  kidney,  and  hot  rectal  irrigations  are  also  useful.     The  diet 


Fig.  49. — Roentgenogram  showing  multiple  calculi  in  the  right  kidney.      {Courtesy  of 

Dr.    Loux.) 

should  be  light  and  nutritious.  Surgical  intervention  becomes 
necessary  when  the  stone  is  impacted,  threatening  suppuration, 
hydronephrosis,  or  pyonephrosis.  Nephrolithotomy  is  the  operation 
of  choice  in  these  cases. 


TUMORS. 

The  benign  growths  frequently  found  in  the  kidney  are:  papil- 
loma^ fibroma,  adenoma,  and  lipoma.     These  may  be  either  in  the 


184  SURGICAL  AFFECTIONS    OF    THE   KIDNEY. 

pelvis  or  kidney  proper.  Sarcomata  and  adenomata  constitute  the 
malignant  type.  Cysts  may  also  occur  in  the  kidney  but  are  rare. 
The  benign  neoplasm  rarely  gives  rise  to  any  serious  disturbances 
and  may  exist  during  the  life  of  an  individual  without  even  being 
noticed.  Sarcomata  are  most  frequently  found  in  children  and 
infants  but  may  occur  during  adult  life.  Adenomata  are  found 
in  the  cortex  of  the  kidney  and  may  remain  small  for  years  while 
in  some  cases  they  may  rapidly  undergo  carcinomatous  changes. 

Symptoms. — The  symptoms  of  renal  neoplasm  are  generally 
very  obscure,  rendering  the  diagnosis  very  difficult.  Pain  may  be 
present  or  absent,  and  is  not  characteristic  of  tumor.  Hmmatiiria 
is  also  a  common  symptom.  Emaciation,  anaemia,  nausea,  and 
vomiting  are  all  more  or  less  constant  symptoms. 

Treatment. — A  diagnosis  having  been  clearly  established,  e.g., 
by  an  exploratory  incision  and  the    competency  of  the  opposite 

kidney  ascertained.     Nephrectomy  is  the  favorite  operation. 

* 

CYSTS  OF  THE  KIDNEY. 

These  may  be  congenital  or  acquired,  large  or  small,  single  or 
multiple.  They  may  be  situated  either  in  the  pelvis  or  kidney 
substance  proper.     Hydatid  cysts  of  the  kidney  are  very  rare. 

Treatment. — Nephrectomy  and  drainage  is  usually  all  that  is 
necessary,  but  in  severe  cases  partial  or  complete  nephrectomy  may 
be  performed. 

FLOATING  OR  MOVABLE  KIDNEY. 

Dislocation  of  the  kidney  or  nephroptosis,  as  this  condition  is 
sometimes  called,  occurs  in  two  forms:  movable  kidney,  in  which 
the  organ  is  situated  behind  and  outside  of  the  peritoneal  cavity, 
and  FLOATING  KIDNEY,  or  that  form  which  is  completely  enveloped 
by  a  fold  of  peritoneum  and  is  supplied  by  a  mesonephron  which 
allows  the  kidney  to  move  about  freely  in  the  peritoneal  cavity. 

Etiology. — It  occurs  more  frequently  in  females  than  in  males, 
and  is  supposed  to  be  due  to  laxity  of  the  abdominal  walls  as  a  result 


FLOATING    OR    MOVABLE    KIDNEY.  1 85 

of  pregnancy  and  to  absorption  of  the  fat  around  the  kidney  in 
consequence  of  emaciation  occurring  in  wasting  diseases.  The  least 
muscular  effort  is  often  sufficient  to  loosen  the  kidney  from  its 
attachments. 

Symptoms. — Gastro-intestinal  disturbances,  e.g.,  flatulence, 
dyspepsia,  almost  invariably  attend  the  condition  of  movable 
kidney.  As  described  by  Edebohls  pain  is  felt  in  the  epigastrium 
which  is  not  increased  by  pressure.  General  nervousness  accom- 
panied by  cardiac  palpitation,  sleeplessness,  irritability  of  temper 
also  accompany  this  train  of  symptoms.  The  patient  experiences 
the  sensation  of  something  moving  about  in  the  abdomen.  Intense 
pain  due  to  sudden  kink  of  the  ureter  known  as  DieWs  crisis  may 
be  encountered  in  these  cases;  with  this,  symptoms  of  general 
prostration,  nausea  and  vomiting,  fever,  chills,  etc.,  are  not  un- 
common. 

Diagnosis. — In  thin  subjects  by  bi-manual  palpation  of  the 
flank,  the  movable  kidney  may  be  usually  recognized. 

How  TO  Palpate  a  Movable  Kidney. — In  conducting  this 
examination,  the  patient  either  stands  while  the  manipulator  is 
seated  or  both  may  be  standing.  The  patient  may  also  lie  on  his 
back,  or  on  either  side,  depending  on  the  side  to  be  examined.  The 
patient  is  then  told  to  take  a  deep  breath  while  pressure  with  one 
hand  over  the  lumbar  region  between  the  fixed  border  of  the  ribs 
and  the  crest  of  the  ilium  forces  the  organ  upward,  while  the  hand 
on  the  abdomen  gently  presses  toward  the  hand  on  the  back. 

Prognosis. — A  movable  kidney  is  never  fatal  in  itself,  but  the 
danger  sometimes  lies  in  its  consequence.  Surgical  measures  are 
usually  necessary  because  a  dislocated  kidney  rarely  becomes 
fastened  in  place  again  by  any  other  means. 

Treatment. — An  elastic  abdominal  bandage  about  5  inches  wide 
encircling  the  abdomen  between  the  ribs  and  iliac  crest  with  a  loose 
kidney  pad  inserted  over  the  caecum.  The  upward  pressure  thus 
comes  from  below,  crowding  the  viscera  higher  into  the  abdominal 
cavity  and  thereby  supporting  the  kidney.  Corsets  and  braces  of 
various  kinds  have  also  been  devised  for  this  purpose.     Gallant's 


i80  SURGICAL   AFFECTIONS    OF    THE    KIDNEY. 

corset  is  perhaps  the  most  popular  one  used.  When  these  methods 
fail,  nephrorrhaphy  (fixation  of  the  kidney)  should  be  advised. 
If  this  be  unsuccessful,  nephrectomy  must  be  performed  as  a  last 
resort  after  first  ascertaining  that  the  opposite  kidney  is  function- 
ating normally.  This  operation  unfortunately  has  a  very  high 
mortality,  therefore  should  only  be  done  in  extreme  cases — where 
there  is  no  other  alternative. 

TRAUMATISMS. 

The  kidney  may  be  the  seat  of  direct  violence  producing  con- 
tusion of  the  organ  or  the  injury  may  be  due  to  stab  or  gunshot 
wounds.  The  treatment  depends  upon  the  extent  of  the  injury, 
the  judgment  and  experience  of  the  surgeon. 

SUPPURATIVE  AFFECTIONS  OF  THE  KIDNEY. 

The  suppurative  inflammations  of  the  kidney  or  of  its  pelvis  or 
both  together  are  pyelitis,  pyelonephritis,  pyonephrosis,  suppurati\'8 
nephritis,  and  perinephritis. 

Pyelitis  and  Pyelonephritis. — These  two  conditions  are  so 
intimately  allied  that  they  may  be  described  under  one  heading. 
They  are  usually  the  result  of  inflammation  of  pelvis  of  the  kidney 
and  its  calices  with  consequent  dilatation  of  these  couties.  The 
tissues  of  the  pelves,  calices,  and  even  the  parenchyma  may  be 
included  in  the  inflammatory  process.  The  pathological  changes 
which  take  place  are  acute  and  chronic  hyperaemia  and  congestion 
and  in  severe  cases  infiltration  and  degenerative  changes  in  the 
kidney  structure  due  to  the  secondary  invasion  of  pyogenic  micro- 
organisms. 

Etiology. — Extension  of  the  morbid  inflammatory  process  from 
the  bladder  and  ureters  as  a  result  of  urethral  stricture,  prostatic 
hypertrophy,  and  vesical  paralysis.  This  ascending  infection  may 
result  from  obstruction  of  the  ureter.  In  not  a  few  instances  the 
gonococcus  was  the  infecting  agent.  Descending  pyelitis  and  pye- 
lonephritis may  also  occur  from  the  acute  and  chronic  infectious 


SUPPURATIVE   AFFECTIONS    OF    THE    KIDNEY.  1 87 

diseases  such  as  diphtheria,  typhoid  fever,  pyaemia,  septicaemia, 
caries  of  bones,  appendicitis,  osteo-myelitis,  etc.,  due  as  a  rule  to 
contiguity  of  the  tissue  to  the  infecting  foci.  This  affection  may 
be  of  the  simple  catarrhal  or  suppurative  type.  The  lodgment  of 
sand,  gravel,  or  calculi  may  also  give  rise  to  pyelitis  and  pyelone- 
phritis, which  conditions  are  termed  by  many  as  calculous  pyelitis 
and  pyelonephritis  and  nephrolitliiasis  due  to  irritation  or  obstruc- 
tion. It  is  stated  that  this  affection  is  more  frequent  in  men  than  in 
women.  Traumatism  to  the  kidneys,  foreign  bodies,  malignant 
neoplasms,  may  also  figure  in  the  etiology  of  pyelitis  and  pyelonephri- 
tis. Among  the  other  causative  factors  are  elimination  by  the 
kidneys  of  such  irritant  drugs  as  creosote,  cantharides,  carbolic 
and  turpentine,  balsams,  chloroform,  etc.  Tuberculosis  occurring 
either  primarily  or  secondary  to  the  disease  in  other  structures,  e.g., 
ureter,  bladder,  prostate,  testes,  and  vesicles. 

Pathology. — The  pathology  of  both  pyelitis  and  pyelonephritis 
differs  only  in  degree.  In  pyelitis  the  pelvis  and  calices  are  dilated. 
They  may  contain  pus,  mucus,  and  urinary  concretions.  In 
pyelonephritis  the  organ  is  slightly  increased  in  size,  congested,  and 
dotted  with  foci  of  pus,  enclosed  in  an  area  of  hyperaemia,  which  are 
minute  abscesses  due  to  microbic  infection.  These  sooner  or  later 
coalesce  forming  larger  abscesses  involving  the  pelvis,  calices,  and 
parenchyma  of  the  kidney.  The  walls  of  the  ureters  are  inflamed 
and  thickened  and  may  contain  pus  and  fibrin.  The  various  micro- 
organisms which  cause  inflammation  of  the  kidneys  are  B.  coli  com- 
mune, staphylococci,  streptococci,  tubercle  bacilli,  and  gonococci. 

One  or  both  kidneys  may  be  attacked  by  a  chronic  pyelonephritis. 

Symptoms. — The  condition  may  be  so  mild  that  the  only 
symptoms  complained  of  by  the  patient  will  be  slight  pain  in 
the  loins.  In  acute  cases  (which  are  rare),  usually  produced 
by  gravel  and  chemical  irritants,  and  coming  on  suddenly,  he 
will  suffer  from  headaches  fever,  chills,  sweating,  dry  tongue, 
nausea,  and  great  weakness.  The  pain  in  the  loins  is  aggra- 
vated by  pressure  or  deep  respiration  and  motion.  The  urine 
is  scant  and  contains  mucus,  pus,  blood,  and  renal  epithelium.     The 


1 88  SURGICAL  AFFECTIONS    OF    THE    KIDNEY. 

pain  sometimes  is  reflected  into  the  penis  and  testicles.  In  chronic 
pyelitis  with  pus  formation  the  symptoms  are  more  marked.  The 
pain  is  more  severe.  This  may  or  may  not  be  polyuria  but  the 
amount  of  pus  present  is  increased  and  in  consequence  of  the  blood, 
pus,  and  mucus,  the  urine  is  highly  albuminous.  The  microscope 
will  show  renal  epithelium,  hyaline  casts,  and  pus  cylinders.  As 
the  condition  becomes  intensified  the  patient  passes  into  a  state  of 
chronic  invalidism.  He  becomes  thin,  weak,  and  anaemic,  loses 
all  appetite  and  suffers  from  fever  and  chills.  Unless  operation  is 
performed  death  inevitably  occurs.  In  ascending  pyelonephritis 
from  a  preexistent  cystitis,  examination  of  the  urine  is  often  unsatis- 
factory, especially  where  ammoniacal  decomposition  has  taken 
place.     In  such  cases  the  lesion  is  not  ascertained  until  at  an  autopsy. 

Diagnosis. — The  important  point  to  determine  in  the  diagnosis 
of  pyelitis  or  pyelonephritis  is  whether  the  condition  is  due  to  ascend- 
ing or  descending  iniection.  This  may  be  usually  accomplished  by 
physical  examinations  and  repeated  microscopic  studies  made  of 
the  urine  and  a  careful  history  of  the  patient's  previous  health, 
habits,  etc.  As  an  aid  to  the  diagnosis  in  these  cases,  catheteriza- 
tion of  the  ureters,  cryoscopy,  and  segregation  may  be  of  much  value 
in  determining  the  extent  and  the  character  of  the  lesion  and  whether 
the  condition   is  unilateral  or  bilateral,  the  presence  of  calculi,  etc. 

Treatment  of  pyelitis  consists  in  keeping  the  patient  in  bed, 
giving  a  light  nutritious  diet,  local  applications,  or  counterirritation 
and  the  skin  kept  active  by  hot  baths.  The  urine  should  be  ren- 
dered bland  and  the  patient  allowed  to  drink  of  the  mineral  waters 
freely.  Pain,  if  severe,  relieved  by  morphia.  Operation  must  be 
deferred  until  the  acute  symptoms  subside.  If  the  pyelitis  is  due 
to  obstruction,  the  cause  ascertained  and  removed  by  surgical 
measures,  if  necessary.  Ureteral  calculi  can  often  be  dislodged  by 
the  ureteral  catheter  and  an  oil  injection  (see  p.  224).  In  pyelo- 
nephritis the  treatment  is  practically  the  same  as  for  pyelitis. 
It  is  important  in  this  condition  to  administer  urotropin,  boric 
acid,  and  salol  so  as  to  keep  the  urine  aseptic.  Otherwise  the 
principles  of  treatment  are  identical  with  those  of  pyelitis. 


OPERATIONS  ON  THE  KIDNEY.  1 89 

Renal  tuberculosis  when  of  primary  development  is  not  attended 
with  any  weH  marked  symptoms.  Where  the  affection  is  second- 
ary to  tubercular  lesions  of  other  structures,  it  may  not  become 
manifest  until  the  patient  complains  of  pain  in  the  loins,  and  by 
frequent  and  sometimes  painful  micturition.  These  wiU  eventually 
be  accompanied  by  gradual  emaciation,  hectic  fever,  pyuria  and 
night  sweats,  and  vesical  tenesmus  unless  relieved  by  an  operation. 
The  kidney  may  be  palpably  enlarged.  Microscopicahy  the  urine 
will  be  found  to  contain  blood,  pus,  renal  epithelium,  tissue  detritus, 
and  tubercle  bacilli.  The  quantity  of  blood  lost  is  variable,  may 
be  slight  or  copious,  occurring  at  regular  intervals. 

Diagnosis. — In  early  cases  the  diagnosis  must  depend  upon 
the  findings  of  the  cystoscope  and  the  presence  of  tubercle  bacilli 
in  the  urine.  The  loss  of  weight,  anaemia,  and  the  existence  of  tu- 
berculous processes  elsewhere  will  usually  furnish  sufficient  data 
to  establish  a  clear  diagnosis  of  all  the  forms  of  pyelitis  and  pyelo- 
nephritis. 

Treatment. — The  extent  of  involvement  of  the  bladder  and 
the  presence  of  tuberculosis  elsewhere  have  an  influence  on  the 
course  of  treatment.  If  the  anti-tuberculous  treatment  is  of  no 
benefit  and  pus  should  form,  it  must  be  evacuated  by  a  lumbar 
incision  or  nephrotomy.  Nephrectomy  is  a  dangerous  procedure 
because  of  the  fact  that  the  other  kidney  is  likely  to  be  attacked  by 
the  process  sooner  or  later.  If  possible,  patients  suffering  with 
renal  tuberculosis  should  be  removed  to  a  suitable  climate  and  given 
energetic  constitutional  treatment. 

OPERATIONS  ON  THE  KIDNEY. 

The  kidney  may  be  accessible  for  palpation,  exploration,  and 
extirpation  through  the  posterior  abdominal  wall,  by  incision  in  the 
anterior  abdominal  wall.  The  former  or  extra-peritoneal  route  is 
much  preferred  as  it  avoids  injury  to  the  peritone.um  with  less 
danger  of  peritonitis.  The  presence  and  condition  of  the  opposite 
kidney  should  always  be  ascertained  before  undertaking  any  opera- 


190  SURGICAL   AFFECTIONS    OF    THE    KIDNEY. 

tion  on  the  kidney.  The  various  incisions  designed  to  reach  the 
.kidney  are  as  follows: 

The  Simon  or  vertical  incision  is  made  from  the  eleventh  rib  along 
the  outer  border  of  the  erector  spinae  muscle  to  the  iliac  crest.  The 
subcutaneous  fat  and  latissimus  dorsi  and  transversalis  fascia  being 
divided  to  the  same  extent  and  retracting  the  fibres  of  the  quadratus 
muscle,  cutting  the  fascia  beneath  it  when  the  fatty  capsule  of  the 
kidney  comes  into  view. 

Czerny's  incision  is  oblique,  extending  from  an  inch  below  the 
twelfth  rib  and  parallel  to  it  from  the  outer  border  of  the  erector 
spinae  downward  and  outward  for  the  required  distance  carrying 
it  to  the  level  of  and  toward  the  umbilicus. 

Koenig's  incision  consists  in  a  V  shaped  incision,  beginning  at 
the  lower  border  of  the  twelfth  rib,  extending  down  on  a  straight 
line  along  the  outer  edge  of  the  erector  spinal  muscle  until  the  level 
of  the  umbilicus  is  reached  when  it  turns  forward  almost  at  right 
angles  toward  the  umbilicus  for  the  required  distance. 

An  incision  made  in  the  linea  alba  or  in  the  linea  semilunaris  is 
advised  by  Langenbuch  in  providing  access  to  renal  tumors.  The 
lateral  incision  is  made  through  the  linea  semilunaris  from  the 
costal  cartilage  downward  to  as  near  Poupart's  ligament  as  may  be 
necessary. 

Nephrotomy  consists  in  making  an  incision  into  the  kidney  for 
exploratory  purposes  or  for  drainage  in  suppurative  conditions  and 
hydronephrosis  and  is  always  conducted  through  the  loins. 

Technic. — The  ether  is  administered  preferably  by  means  of 
the  Stellwagen  ether  inhaler  as  shown  by  the  accompanying  illustra- 
tion. (Fig.  50.)  From  a  glance  its  advantages  to  the  reader  must 
be  obvious,  particularly  in  operations  on  or  about  the  kidney. 
The  patient  is  then  placed  on  the  opposite  side  with  a  sand  bag 
pressing  into  the  flank.  The  kidney  is  now  forced  up  into  the  loin 
by  pressure  on  the  anterior  abdominal  wall.  The  kidney  may  be 
exposed  by  any  one  of  the  various  lumbar  incisions  described  above, 
but  preferably  by  the  oblique  (Koenig's)  incision,  care  being  taken 
to  avoid  injury  to  the  pleura.     The  field  of  operation  should  be  kept 


NEPHRECTOMY. 


191 


dry  as  possible.  The  fatty  perirenal  capsule  having  been  exposed, 
is  torn,  through  and  the  kidney  brought  into  the  wound,  whose  walls 
are  retracted.  An  incision  is  now  made  into  the  kidney  pelvis  through 
the  outer  border,  and  the  organ  explored  and  any  abnormal  contents 
evacuated,  and  the  cavity  drained  with  strips  of  gauze  or  a  rubber  tube 
around  which  the  wound  is  packed  and  one  or  two  sutures  taken  at 
each  angle.  In  hydronephrosis,  drainage  is  unnecessary.  The 
kidney  wound  may  be  closed  with  sutures  and  the  outer  wound  treated 
likewise. 


Fig.   50. — Stellwagen's  Ether  Inhaler. 

Nephrolithotomy. — This  consists  in  the  performance  of  nephrot- 
omy as  just  described  for  the  removal  of  renal  calculi.  Hemorrhage 
which  may  sometimes  be  profuse  in  this  operation  may  be  controlled 
by  digital  compression  of  the  artery  or  by  gauze  pressure.  After  the 
stone  is  extracted  by  proper  forceps  the  wound  of  the  kidney  may  be 
united  by  deep  and  superficial  sutures  and  the  external  wound 
closed  with  or  without  drainage. 

Nephrectomy. — Total  removal  of  the  kidney  is  performed  either 
by  the  lumbar  or  abdominal  route.  The  former  is  the  operation 
of  choice.  The  indications  for  this  operation  are — extensive  in- 
juries to  the  kidneys  or  ureters,  tumors  of  the  kidney,  intractable  renal 


192  SURGICAL   AFFECTIONS    OF    THE    KIDNEY. 

fistulae,  surgical  kidney,  renal  tuberculosis,  and  rarely  for  movable 
kidney.  The  existence  and  condition  of  the  other  kidney  must  be 
ascertained  previous  to  the  operation — a  step  of  the  utmost  import- 
ance. Lumbar  nephrectomy  consists  in  making  a  lumbar  incision, 
bringing  the  kidney  well  up  into  the  wound,  freeing  it  from  all  its 
attachments  or  adhesions,  ligating  the  vessels  arid  ureter,  and  divided 
between  the  tw.o  ligatures.  The  wound  should  then  be  closed  or 
drained,  packed  and  partially  sutured,  as  may  be  necessary.  Ab- 
dominal nephrectomy  is  the  same  in  its  principles  as  by  the  lumbar 
route  except  that  the  abdominal  incision  is  made  in  the  linea  semi- 
lunaris. After  the  kidney  is  enucleated  as  in  the  lumbar  operation 
the  peritoneum  is  sutured  over  the  perirenal  fat  and  the  abdominal 
wound  closed  unless  there  is  some  contraindication. 

Nephrorrhaphy  or  Nephropexy. — ^Fixation  of  movable  kidney 
is  performed  by  making  a  lumbar  incision,  preferably  the  Simon  or 
vertical  incision,  and  anchoring  the  kidney  in  its  normal  position  by 
passing  several  silk  or  gut  sutures  through  its  substance  from  its 
anterior  to  its  posterior  surface  below  the  convex  border  and  then 
through  the  lumbar  fascia  so  that  when  these  sutures  are  tied,  the 
kidney  is  held  firmly  against  the  posterior  abdominal  wall.  The 
edges  of  the  parietal  wound  may  be  approximated  or  left  open  for 
drainage.  When  this  method  fails  to  hold  the  kidney  in  place  and 
several  attempts  have  been  tried,  nephrectomy  is  advised  by  many 
surgeons. 

RENAL  DECAPSULATION  OR  REMOVAL  OF  THE  PERI- 
RENAL CAPSULE. 

Edebohls  says:  "Renal  decapsulation  is  performed  with  the 
object  in  view  of  creating  new  and  liberal  supplies  of  arterial 
blood  to  the  diseased  kidney.  The  denuded  kidney  and  its  fatty 
capsule  are  most  liberally  supplied  with  blood  vessels.  Both  are 
brought  together  by  the  operation  over  the  entire  surface  on  the 
kidney,  and  new  and  large  blood  vessels  form  between  the  kidney 
and    the    surrounding    fatty   tissue.     The  normal   capsule   of   the 


RENAL    DECAPSULATION.  1 93 

kidney  forms  a  barrier  to  this  new  supply  of  blood  made  possible 
by  a  decapsulation." 

This  increase  of  blood  supply  to  the  kidneys  which  Edebohls 
claims  to  occur  improves  the  circulation  in  the  organ  and  assists  in 
removing  waste  products.  The  portion  of  the  kidney  not  diseased 
takes  on  an  increased  function  and  the  disease  might  be  checked. 

It  has  been  observed  that  a  factor  which  probably  has  consider- 
able to  do  with  the  improvement  which  is  noticed  during  the  first 
few  days  after  a  decapsulation  is  the  massage  which  the  kidneys 
receive  at  the  hands  of  the  surgeon  during  the  operation.  It  seems 
plausible  to  believe  that  this  manipulation  temporarily  relieves  the 
congestion  and  inflammation  which  exists.  Considerable  testimony 
has  accumulated  pointing  to  the  improvement  being  due  to  the  relief 
of  renal  tension  by  decapsulation. 


13 


CHAPTER  X. 

AFFECTIONS  OF  THE  BLADDER. 

CYSTITIS. 

Tlie  various  types  of  inflammation  of  the  urinary  bladder  depend 
for  their  classification  largely  upon  the  etiological  factor,  their 
being  designated  accordingly  and  are  as  follows: 

Varieties. — When  due  to  bacteria  it  is  termed  septic  or  sup- 
purative CYSTITIS.  Inflammation  due  simply  to  irritants  and  not 
bacteria  which  is  of  short  duration  constitutes  the  so-called  aseptic 
or  simple  cystitis. 

Septic  cystites  have  been  subdivided  into  suppurative,  simple, 
and  chronic;  catarrhal;  ulcerative  (hemorrhagic),  membranous  (or 
diphtheritic),  and  tubercular  cystitis. 

Pericystitis  or  inflammation  of  the  tunica  adventitia. 

Paracystitis  or  inflammation  of  the  tissues  surrounding  the 
bladder. 

Etiology. — Cystites  occurring  during  the  course  of  acute 
infectious  diseases,  e.g.,  typhoid,  scarlet  fever,  and  diphtheria, 
constitutional  diseases,  particularly  diabetes  and  gout,  and  the 
septic  conditions  such  as  erysipelas  and  pyaemia.  Vesical  paralysis 
due  to  paraplegia  or  myelitis  may  also  give  rise  to  inflammation 
of  the  bladder. 

Chemic  irritants,  e.g.,  turpentine,  cantharides,  ammonia,  and 
strong  instillations  may  give  rise  to  cystitis. 

Exposure  to  told  and  wet  and  traumatism  may  cause  cystitis. 

Decending  infection  from  the  ureters  and  kidney  and  ascending 
infection  from  the  urethra  are  very  prolific  sources  of  bladder 
infection. 

Vesical  calculus,  tumor,  and  prostatic  disease  may  also  cause 
cystitis. 

194 


CYSTITIS.  195 

Cystitis  is  a  very  common  sequel  of  gonorrhcea  and  is  often 
due  to  instrumentation  during  the  course  of  the  disease,  or  the 
infection  of  the  bladder  occasioned  by  contiguity. 

Cystitis  commonly  originates  from  the  use  of  rough  or  unclean 
instruments. 

Residual  urine  occurring  as  a  result  of  stricture  and  enlarged 
prostate  may  cause  inflammation  of  the  bladder  due  to  irritation 
of  the  decomposed  and  sometimes  infected  urine. 

The  bacillus  coli  communis  is  found  in  the  majority  of  cases 
usually  in  an  acid  urine. 

The  uro-hacillus  liquifaciens  is  another  important  organism 
found  principally  in  neutral  or  alkaline  urines  and  has  the  power 
of  decomposing  urea,  causing  the  urine  to  become  alkaline  within  a 
few  hours. 

The  streptococcus  pyogenes,  staphylococci,  and  diplococci  have  also 
been  found  in  the  urine  in  cystitis. 

Pathology. — Congestion  of  the  bladder  undoubtedly  predis- 
poses to  cystitis;  in  chronic  congestion  there  is  always  more  or  less 
round  cell  infiltration  and  proliferation  of  connective  tissue,  impair- 
ing the  vitality  of  the  part,  and  rendering  the  tissues  extremely  sus- 
ceptible to  infection  by  pyogenic  micro-organisms. 

In  nearly  all  cases  of  chronic  cystitis,  hypertrophy  of  the  muscular 
coat  with  subsequent  fatty  degeneration  and  dilatation  or  sometimes 
fibrous  overgrowth  causing  contraction  and  muscular  atrophy; 
the  bladder  is  in  these  cases  perhaps  ribbed  and  sacculated,  forming 
a  favorable  lodgment  of  calculi,  due  to  precipitate  of  decomposed 
and  ammoniacal  urine,  usually  on  the  posterior  wall.  In  extreme 
conditions  there  are  often  produced  false  diverticulae  due  to  pro- 
trusion of  the  vesical  mucous  membrane  through  a  weakened  area 
of  the  muscularis. 

Urinary  Signs. — The  microscopic  appearance  of  the  urine 
may  show  but  little  change  and  may  be  acid  or  neutral  in  reaction. 
On  standing,  a  light  sediment  collects  and  the  supernatant  urine 
becomes  clear,  where  previously  it  was  more  or  less  turbid.  Where 
there  is  considerable  pyuria,  albumin  is  present  as  a  constituent  of 


196  AFFECTIONS    OF    THE    BLADDER. 

pus.  Blood  may  also  be  contained  in  the  urine  and  may  be  scant 
or  profuse  as  clots.  In  most  cases  the  urine  will  be  found  neutral, 
alkaline  in  reaction,  and  ammoniacal.  It  is  turbid,  and  contains 
pus  and  sediment.  Upon  standing  the  supernatant  urine  does 
not  become  clear.  Microscopically  there  will  be  found  degenerated 
pus  cells,  vesical  epithelium,  fragments  of  tissue,  necrosed  mem- 
brane, crystals  of  triple  phosphates,  ammonium  urates,  and  hyaline 
tube  casts,  cylindroids,  and  bacteria. 

Local  Symptoms. — Pain  is  early  and  constant  over  the  pubes  or 
in  the  perineum  and  often  aggravated  by  micturition,  which  may 
be  spasmodic  and  straining  in  character  preceding  the  act  and 
relieved  when  the  bladder  is  empty.  Other  times  there  may  be 
burning  along  the  urethra  during  urination,  and  especially  severe 
at  the  meatus  and  may  continue  some  time  thereafter.  The  pain 
is  significant  of  the  severity  of  the  inflammation,  the  degree  of 
obstruction,  presence  of  stone,  ulceration,  etc. 

Frequency  of  Urination. — Attends  all  cases  of  cystitis  as  the 
condition  advances.  This  is  usually  due  to  irritation  and  decreased 
capacity  through  oversensitive  mucous  membrane  and  contracted 
bladder  walls.  Vesical  tenesmus  is  constant  in  all  marked  cases  of 
increased  frequency  of  urination. 

Constitutional  Symptoms. — Fever,  chills,  and  sweating  often 
accompany  the  acute  form  of  cystitis.  Gastro-intestinal  dis- 
turbances, e.g.,  loss  of  appetite,  dyspepsia,  flatulence,  and  constipa- 
tion likewise  frequently  occur.  Headache,  vertigo,  insomnia,  and 
irritability  of  temper  are  also  a  few  of  the  nervous  features  often 
encountered.  Symptoms  of  septicaemia  and  pyaemia  must  be  care- 
fully noted,  especially  in  severe  cases  where  there  are  damaged  kid- 
neys as  a  complication. 

Prognosis. — In  simple  cystitis  it  is  always  favorable.  When 
due  to  infection  it  must  be  rendered  according  to  the  extent  of  the 
involvement  and  the  accompanying  complications.  The  danger  of 
ascending  infection  must  be  remembered. 

Diagnosis. — None  of  the  symptoms  are  pathognomonic  of  any 
one  form  of  cystitis,  therefore  definite  conclusions  cannot  be  reached 


CYSTITIS.  197 

until  cystoscopic  examination  has  been  made.  By  this  modern 
acquisition  to  diagnosis,  the  recognition  of  the  various  diseases  of 
the  urinary  bladder  is  comparatively  easy.  It  cannot  be  used, 
however,  in  acute  cases  as  it  would  only  increase  the  irritation. 
In  chronic  cases  the  cystoscope  is  indispensable.  By  its  use  the 
presence  of  calculi,  tuberculosis  of  the  bladder,  and  malignancy  of 
the  presence  of  enlarged  prostate  can  be  readily  recognized. 

Treatment. — The  cause  of  the  cystitis  must  always  be  ascertained 
and  then  such  measures  adopted  as  will  remove  it  if  possible,  and 
repair  the  damaged  tissues.  The  acuteness  and  the  severity  of  the 
attack  and  the  changes  in  the  urine  as  well  as  any  form  of  obstruction 
to  the  free  outflow  of  the  urine  and  the  condition  of  the  kidneys, 
ascertained  by  urinary  analysis,  all  serve  as  a  guide  to  the  method 
of  treatment  to  employ.  In  acute  cystites  the  rest  in  bed  is  impera- 
tive until  the  acute  symptoms  subside.  The  diet  should  be  light, 
nutritious,  and  easily  digested,  e.g.,  milk,  eggs,  bland  table  waters, 
plain  soups,  and  broths.  The  patient  should  avoid  red  meats,  green 
vegetables,  and  highly  seasoned  foods,  also  alcohol,  coffee,  and  cocoa. 
The  skin  must  be  kept  active  by  warm  baths,  followed  by  an  alcohol 
rub  and  massage.  The  bowels  should  be  kept  regular  by  laxatives 
if  necessary.  If  there  be  much  pain,  hot  sitz  baths  together  with 
hot  rectal  irrigations  will  give  much  relief.  This  may  be  subor- 
dinated by  hot  applications  over  the  bladder  and  on  the  perineum. 

Tenesmus  may  be  considerably  relieved  by  suppositories  of 
opium  and  belladonna  and  internally  by  morphia  by  mouth  or  by 
hypodermic  injections.  Where  there  is  hyperacidity  of  the  urine, 
some  alkaline,  preferably  sodium  or  potassium  bicarbonate,  is 
beneficial.  This  may  be  combined  with  tincture  of  hyocyamus. 
Vichy,  either  alone  or  with  milk,  is  also  efficacious  in  these  cases. 
Any  symptoms  of  retention  must  be  immediately  combated  by  the 
hot  applications  and  catheterization  if  necessary.  In  the  subacute 
should  there  be  irritability  of  the  bladder  and  deep  urethra,  with 
frequency  of  urination,  it  is  often  relieved  by  the  instillation  of  a  few 
drops  of  nitrate  of  silver  solution  (2  grs.  to  the  ounce)  into  the  deep 
urethra  through  a  soft  rubber  catheter  or  by  means  of  a  Keyes- 


198  AFFECTIONS    OF    THE    BLADDER. 

Ultzmann  syringe.  Should  the  condition  progress  into  the  chronic 
stage,  boric  acid,  salol  (the  latter  where  the  urine  is  alkaline),  in 
doses  from  5  to  7  grains  t.i.d.,  may  be  given.  Oil  of  eucalyptus  has 
also  been  recommended  in  chronic  cystitis.  The  bladder  should  be 
irrigated  at  least  once  daily  with  warm,  mild  antiseptic  solutions, 
through  a  soft  rubber  catheter.  The  capacity  of  the  bladder  should 
be  noted  and  when  the  patient  experiences  the  first  sense  of  fullness, 
the  catheter  is  withdrawn  and  he  is  either  allowed  to  evacuate  the 
fluid  alone  or  it  may  be  allowed  to  drain  off  through  the  catheter, 
and  the  washings  thus  continued  until  the  fluid  comes  away  clear. 
By  not  continuing  beyond  the  feeling  of  fullness,  over-distention  of 
the  bladder  is  avoided.  The  solutions  employed  for  this  purpose  are 
boric  acid  (saturated  sol.),  normal  saline  solution,  salicylic  acid 
(3  to  1000  to  break  up  adherent  gelatinous  pus),  oxy cyanide  of 
mercury  (i  to  8000),  potassium  permang.  (i  to  4000),  and  (probably 
best  of  all)  nitrate  of  silver  beginning  with  strengths  1-8000  and 
increasing  up  to  i  to  1000.  Instillations  of  20  drops  Ag.  No.  3 
(i  to  5  grs.  to  the  ounce)  every  2d  or  3d  day  is  also  recommended. 

Cystitis  complicated  by  calculus,  stricture,  tumor,  foreign  body, 
enlarged  prostate,  all  call  for  surgical  intervention. 

VESICAL  CALCULUS. 

Stone  in  the  bladder  may  originate  either  in  the  bladder  or  in  the 
kidney,  but  probably  the  greater  number  come  from  the  kidney, 
this  being  especially  true  of  calculi  containing  uric  acid  nucleus. 
Stone  never  forms  primarily  in  a  perfectly  normal  bladder.  The 
composition  of  calculi  consists  chiefly  of  uric  acid  and  urates,  oxalates 
and  phosphates,  each  of  which  has  definite  characteristics.  They 
increase  rapidly  in  size  and  weight  by  the  addition  of  superimposed 
layers  around  the  nucleus  of  any  of  these  salts  according  to  the 
chemical  composition  of  the  urine.  These  constituents  are  held 
together  by  the  mucous  element,  without  which  stone  formation 
does  not  occur.  Calculus  may  be  single  or  double,  being  lodged  in 
the  post-trigonal  pouch.     When  more  than  one,  the  surfaces  are 


VESICAL    CALCULUS.  1 99 

usually  faceted  and  smooth.  They  may  be  free,  adherent  or  en- 
cysted in  the  bladder  walls;  vary  in  size  and  shape,  and  may  weigh 
from  a  few  grains  to  several  ounces.  Oxalate  of  lime  calculi 
(mulberry  calculus)  are  dark  gray  in  color,  presenting  rough  sur- 
faces and  very  hard  in  structure.  Stones  of  uric  acid  and  urates  are 
yellow  or  yellowish  red  and  soft.  Phosphatic  calculi  consist  of 
phosphates  and  carbonates,  are  light  gray  in  color,  very  soft,  and 
present  a  slightly  roughened  surface. 

Calculus  originating  in  a  diseased  bladder  frequently  has  for  its 
nucleus  blood  clots,  pus,  and  foreign  bodies,  these  being  superim- 
posed by  the  addition  of  urinary  salts. 

Symptoms. — The  presence  of  stone  in  the  bladder  may  or  may 
not  be  attended  with  any  marked  symptoms.  Usually,  however, 
where  the  calculus  is  the  least  bit  roughened  or  has  attained  any  size, 
and  where  the  bladder  is  filled  with  urine,  it  will  give  rise  to  a  dull 
aching  pain  above  the  symphysis  and  in  the  groins,  also  in  the  thighs, 
testes,  urethra,  and  in  the  glans  penis,  often  radiating  through  the 
perineum  and  rectum.  This  is  aggravated  by  motion  and  relieved 
if  the  patient  is  in  a  recumbent  position.  This  is  due  to  the  fact 
that  if  the  bladder  is  full  the  stone,  if  free,  is  thrown  up  against  the 
sensitive  vesical  orifice.  Reflex  pains  in  the  sole  of  the  foot  and  big 
toe  are  also  common.  Priapism  may  sometimes  occur  as  a  result 
of  stone  in  the  bladder.  Frequency  of  micturition  is  another  not 
infrequent  symptom  with  sudden  stoppage  of  the  urine  during  the 
act.  HcBmaturia  is  often  seen  and  is  due  to  injury  to  the  bladder 
mucous  membrane  but  is  usually  slight.  Cystitis  as  a  rule  super- 
venes unless  the  stone  is  removed. 

Diagnosis. — The  patient  lies  on  his  back  with  head  and  shoulders 
slightly  elevated,  the  bladder  is  then  drained  and  irrigated  and  care- 
fully explored  by  means  of  a  Thompson  stone  searcher  (see  Fig.  51). 
It  is  well  to  leave  about  6  ounces  of  the  irrigating  solution  remaining 
so  as  to  slightly  distend  the  bladder  walls.  The  sound  being  gently 
inserted  for  its  full  length  and  gently  rotated  in  such  a  manner  as 
to  touch  all  parts  of  the  bladder  cavity  especially  the  trigone.  The 
presence  of  stone  is  easily  detected  by  a  sharp  click,  appreciable 


200 


AFFECTIONS    OF    THE    BLADDER. 


to  the  touch  when  it  comes  in  contact  with  the  instrument,  unless 
it  be  thickly  coated  with  pus  or  blood  or  if  it  should  be  encysted 
When  the  searcher  fails,  a  direct  ocular  examination  of 
the  interior  of  the  bladder  may  be  made  with  the  cys- 
toscope.  The  X-ray  in  such  cases  is  another  valuable 
aid  to  diagnosis,  though  this  may  sometimes  fail  to 
show  the  stone.  The  litholapaxy  pump  may  be  be  used 
where  the  stone  searcher  fails.  The  tube  is  inserted  and 
water  forced  into  the  bladder  with  the  bulb.  By  this 
procedure,  when  the  water  drains  off,  the  stone  strikes 
against  the  instrument  and  a  click  is  felt  or  heard.  In 
extreme  cases  and  as  a  last  resort,  a  suprapubic  cysto- 
tomy may  be  performed  for  the  purpose  of  exploration. 
Treatment. — If  there  is  an  excess  of  crystals  in  a 
freshly  voided  urine  or  a  passing  of  sand  or  gravel,  their 
chemical  composition  should  be  ascertained  and  such 
preventative  measures  should  be  taken  as  are  calculated 
to  correct  the  diathesis  and  render  the  urine  normal  if 
possible.  The  patient's  general  health  must  be  atten- 
ded to,  by  ordering  daily  exercise  in  the  open  air,  the 
ingestion  of  large  quantities  of  table  waters.  An  excess 
of  nitrogenous  foods,  e.g.,  meats,  sugar,  fat,  should  be 
forbidden. 

If  the  urine  is  excessively  acid,  the  administration  of 
nitrate  of  potash  is  beneficial.  If  phosphaturia  exists, 
urotropin  7  grs.  should  be  given  three  times  a  day,  and 
10  drops  dilute  hydrochloric  acid  taken  after  meals. 

Operative  Treatment. — When  stone  has  formed  then 
radical  measures  are  indicated.  There  are  various  met- 
hods chief  of  which  are  litholapaxy,  lateral  and  median 
perineal  lithotomy,  and  probably  the  best  of  all  supra- 
pubic cystotomy.  Litholapaxy  consists  in  crushing  the 
stone  and  the  immediate  removal  of  all  its  fragments. 
In  children  and  in  adults  over  61  years  of  age,  when  the 
stone  is  encysted  or  very  large  or  too  hard  this  is  considered  the 


SI. — 


Fig. 
Thompson 
stone 
searcher. 


VESICAL    CALCULUS. 


20I 


operation  of  choice  when  performed  by  an  experi- 
enced operator.  Litholapaxy  is  indicated  only 
where  the  urethra  is  large  enough  to  permit  the 
passage  of  the  instruments  and  where  the  stone  is 
free  and  movable  and  of  a  moderate  size  and  con- 
sistency. Contraindications  to  the  performance 
of  litholapaxy  are  extreme  prostatic  hypertrophy, 
tight  stricture  of  the  deep  urethra,  severe  cystitis, 
contracted  and  irritable  bladder,  nephritis,  and 
suppurative  pyelitis. 

Technic. — After  the  rectum  has  been  thoroughly 
emptied,  the  patient  is  anaesthetized  and  placed  on 
his  back  with  his  hips  elevated  on  a  sand  pillow 
and  his  thighs  separated.  The  bladder  is  irrigated 
with  boric  acid  solution  and  about  6  ounces  left  to 
remain.  A  moderate  size  Bigelow  lithotrite  (Fig. 
52)  is  lubricated  and  passed  through  the  urethra 
and  into  the  bladder,  its  convexity  pressed  down 
against  the  fundus  of  the  bladder  in  the  median 
line  and  its  beak  pointing  upward.  The  jaws  are 
then  separated  when  the  stone  will  usually  roll 
between  them.  They  are  now  closed  slowly  and 
locked  and  gently  rotated  to  ascertain  that  no  vesi- 
cal mucous  membrane  has  been  caught.  By  turn- 
ing, the  blades  or  jaws  are  brought  together  and 
the  stone  reduced  to  fragments.  This  is  repeated 
until  it  is  perceived  that  no  fragments  are  left 
and  the  lithotrite  closed  and  withdrawn.  Evacuat- 
ing of  the  fragments  is  the  next  step.  The  evacuat- 
ing tube  is  introduced  into  the  bladder  and  con- 
nected with  Bigelow's  evacuator  (Fig.  53)  which 
is  filled  with  warm  boric  solution,  and  stop  cocks 
opened,  and  pumping  or  squeezing  of  the  rubber 
bulb  then  begun.  The  fluid  then  flows  out  again 
into   the  glass   receiver   carrying   the   fragments. 


^ 


Si 


»e 


Fig.  52. — Bigelow 
lithotrite  (open). 


202 


AFFECTIONS    OF    THE    BLADDER. 


This  is  continued  until  the  washing  comes  away  clear.  For  children 
small  lithotrites  (size  15  to  20  F.)  have  been  devised.  The  after  treat- 
ment consists  in  keeping  the  patient  in  bed,  allowing  him  to  drink  freely 
of  water,  an  opium  suppository  may  also  be  given  immediately  follow- 
ing the  operation.  The  bladder  and  urethra  are  irrigated  daily  and 
internally    urotropin    or    salol    is    given.     Complications   following 


Fig.   53. — -Bigelow's  evacuator. 

litholapaxy,  e.g./  epididymitis,  urinary  fever,  prostatitis,  must  be 
treated  accordingly. 

Mortality  of  this  operation  according  to  statistics  of  a  large 
number  of  cases  by  Cabot  are  as  follows:  Children  under  14,  1.66 
per  cent.;  adults  14  to  50,  3.25  per  cent.;  adults  past  50,  6  per  cent. 

Perineal  Lithotomy. — This  operation  should  never  be  performed 
on  adults  as  the  suprapubic  route  and  litholapaxy  are  far  superior 
methods.  It  is  only  indicated  in  children  where  litholapaxy  and 
suprapubic  operations  are  contradicted.     The  danger  of  hemorrhage, 


SUPRAPUBIC    CYSTOTOMY. 


20- 


injury  to  the  vesical  neck,  and  inaccessibility  of  the  parts  are  some  of 
its  disadvantages. 

Technic. — The  patient  being  in  the  lithotomy  position,  a  curved 
lithotomy  grooved  staff  is  passed  into  the  bladder  and  held  firmly 
in  the  median  line  by  an  assistant  who  also  holds  the  scrotum  up  out 
of  the  way.  An  incision  is  then  made  three  inches  in  length  either  on 
the  median  line  one  inch  in  front  of,  or  a  little  to  the  left  of,  the  anus, 
downward  and  outward,  being  careful  not  to  wound  the  rectum. 
The  bleeding  is  then  controlled.  The  knife  is  now  entered  on  the 
lateral  groove  of  the  staff  and  following  along  this,  opening  the 


Fig.   54. — Stone  forceps. 

neck  of  the  bladder,  and  cutting  into  the  left  lobe  of  the  prostate. 
The  stone  is  now  grasped  with  forceps  (Fig.  54)  and  extracted,  and 
the  bladder  drained  and  irrigated  in  the  usual  manner. 

In  the  median  operation  the  technic  is  the  same,  with  the  excep- 
tion that  the  staff  has  a  median  groove,  along  which  the  incision 
is  made,  opening  the  membranous  urethra  and  passing  the  finger 
into  the  bladder,  thus  dilating  the  prostatic  urethra,  through  which 
the  stone  is  extracted. 

SUPRAPUBIC  CYSTOTOMY. 

By  many  genito-urinary  surgeons  this  is  considered  the  operation 
of  choice  and  where  litholapaxy  is  contraindicated  it  is  universally 
employed. 

Technic. — The  patient  is  anaesthetized,  placed  upon  his  back, 
with  head  and  shoulders  slightly  elevated  and  a  soft  catheter  passed 
into  his  bladder.  A  collapsed  and  oiled  rectal  bag  is  inserted  into 
the  rectum  by  an  assistant.  The  bladder  is  well  irrigated  by  boric 
acid  solution,  and  8  to  10  ounces  retained  (amount  gauged  by  the 


204  AFFECTIONS    OF    THE    BLADDER. 

capacity  of  the  patient's  bladder).  The  rectal  bag  is  now  distended 
by  injecting  about  8  ounces  of  warm  water  through  the  tube  which  is 
then  clamped  with  a  hemostat.  The  bladder  is  then  raised  up  from 
the  pelvis,  danger  of  injury  to  the  peritoneum  lessened.  An  incision 
is  made  in  the  median  line  upward,  extending  from  a  point  just  above 
the  symphysis  for  a  distance  of  about  three  inches.  The  prevesical 
fat  is  soon  reached  and  pushed  aside  with  the  finger  tip  and  the 
bladder  wall  exposed.  On  each  side  and  into  it  are  passed  silk 
sutures,  which  serve  as  retractors  and  between  which  the  knife  is 
thrust,  and  foUovdng  it  immediately  with  the  fingers  as  the  fluid 
gushes  from  the  wound  and  the  stone  caught  with  the  stone  forceps 
and  gently  removed,  care  being  taken  not  to  injure  the  bladder  edges. 
The  bladder  is  irrigated  and  drained  through  a  large  soft  rubber  tube, 
and  its  edges  sewed  securely  around  the  tube  to  prevent  the  escape  of 
urine  into  the  prevesical  space.  The  abdominal  wound  is  then 
sutured  above  and  below  and  the  centre  left  open  and  packed  with 
sterile  gauze.  In  a  day  or  two  a  smaller  tube  is  inserted  and  a  few 
days  later  the  drainage  removed  altogether  and  the  wound  allowed 
to  granulate.  Any  complicating  cystites  should  be  treated  in  the  usual 
manner  and  continued  until  the  patient  voids  clear  urine. 

TUMORS  OF  THE  BLADDER. 

These  may  be  of  the  benign  or  malignant  type.  The  benign 
GROWTHS  frequently  met  with  are,  papillomata  or  villous  tumors, 
adenoma,  fibroma,  cysts,  myxoma,  and  teratoma.  The  malignant 
TUMORS  are  carcinoma  and  sarcoma.  Vesical  neoplasms  in  most 
cases  are  malignant  and  usually  located  at  the  base  of  the  bladder 
or  near  the  ureteral  openings.  They  may  be  sessile  or  pedunculated 
and  most  frequently  occur  after  middle  life. 

Symptoms. — If  the  growth  is  of  a  benign  character  and  situated 
near  the  vesical  orifice,  it  is  most  apt  to  be  marked  by  frequency  of 
micturition,  hsematuria,  and  interference  of  the  urinary  outflow, 
simulating  the  presence  of  stone.  Pain  is  never  a  prominent  symp- 
tom unless  complicated  with  cystitis.     The  haematuria  comes  on 


TUMORS    OF    THE    BLADDER.  205 

suddenly  and  apparently  without  any  provocation  and  may  last  a 
few  hours  or  many  days;  the  quantity  of  blood  passed  varies. 

Diagnosis. — The  presence  of  vesical  tumor  if  it  be  large  can 
often  be  palpated  by  inserting  one  finger  in  the  rectum  and  making 
deep  pressure  with  the  other  hand  over  the  pubes.  A  careful  review 
of  the  symptoms  and  the  patient's  general  condition  noted  will  usually 
furnish  sufi&cient  data  to  base  a  diagnosis.  Where  there  is  not  much 
bleeding  or  during  the  period  when  the  urine  is  clear,  the  cystoscope 
affords  a  quick  and  accurate  method  of  diagnosis.  An  exploratory 
suprapubic  cystotomy  is  only  indicated  when  all  the  other  measures 
fail. 

Prognosis. — Malignant  growths  usually  recur  after  the  operation, 
owing  to  infiltration  of  the  bladder  wall  and  death  generally  ensues 
in  2  to  3  years  after  commencement  of  the  growth.  Benign  tumors 
when  once  removed  are  not  so  likely  to  recur,  although  they  very 
frequently  do. 

Treatment. — Removal  of  the  growths  especially  in  benign  cases 
should  always  be  advised  as  they  are  apt  to  undergo  malignant 
changes  if  allowed  to  remain,  or  occasion  a  cystitis  with  secondary 
infection  of  the  ureters  and  kidneys.  Hemorrhage  must  be  con- 
trolled by  instillation  of  several  ounces  adrenalin  solution  (i  to  1000) 
or  hot  irrigations  of  alum  solutions  (4  drams  to  the  pint).  The 
patient  should  be  kept  at  rest  in  bed  and  aseptic  ergot  or  adrenalin 
chloride  given  by  the  mouth  or  hypodermically  if  necessary.  If 
there  be  much  clotting  keep  the  bladder  drained  by  means  ,of  a 
large  urethral  catheter. 

FuLGURATiON  treatment  of  papillomata  of  the  bladder  suggested 
by  Beer  offers  an  easy  and  reliable  mode  of  treatment.  It  con- 
sists in  the  application  of  high  frequency  current,  as  a  cauterizing 
agent.  Local  anaesthesia  applied  to  the  mucous  membrane  is  sufh- 
cient  to  eliminate  pain.  It  is  advocated  by  Keys,  Jr.,  and  Buerger, 
as  an  easy  and  effectual  method  of  removing  papillomata  without 
a  cutting  operation  and  surpassing  the  electrocautery  in  the  facility 
with  which  it  can  be  employed  in  the  bladder. 

Suprapubic   cystotomy   is   the   operation  often  done  in  these 


2p6  AFFECTIONS    OF    THE   BLADDER. 

cases.  Pedunculated  growths  should  be  cut  off  at  the  junction 
with  the  bladder  wall.  If  sessile,  part  of  the  bladder  wall  must  be 
resected  in  order  to  remove  all  the  diseased  tissue.  The  hemorrhage 
in  such  cases  must  usually  be  controlled  by  the  actual  cautery,  hot 
irrigations,  and  packing.  The  bladder  is  drained  by  either  a  su- 
prapubic or  perineal  tube  or  both  as  may  be  necessary.  The  tubes 
are  removed  as  soon  as  possible  and  the  wound  allowed  to  granulate 
from  below  and  the  bladder  kept  clean  by  frequent  irrigations  and 
the  urine  rendered  bland  by  internal  medication. 

Teratomata  are  congenital  tumors  containing  embryonal  ele- 
ments from  the  epiblastic,  mesoblastic,  and  hypoblastic  structures 
and  are  most  frequent  in  the  ovary,  testicle,  and  sacral  region.  The 
tumor  may  contain  any  tissue,  adult  or  embryonic,  hence  may  be 
benign  or  malignant.     They  are  to  be  treated  by  excision. 

EXSTROPHY. 

The  condition  of  extroversion  of  the  bladder  is  due  to  defective 
development  of  insufficient  anterior  abdominal  walls  and  the  sym- 
physis pubes.  The  bladder  almost  entirely  bulges  out  of  the  ab- 
dominal cavity.  Treatment  is  surgical  and  consists  of  a  plastic 
operation,  either  with  or  without  transplantation  of  the  ureters. 
The  edges  of  the  bladder  can  in  most  cases  be  sutured  and  then  a 
suitable  apparatus  worn  so  as  to  collect  the  urine  from  its  most  de- 
pendent part,  which  is  easily  removed  without  irritating  the  integu- 
ment or  soiling  the  clothing. 

TRAUMATISMS. 

The  bladder  is  frequently  the  seat  of  incised,  torn,  contused, 
or  punctured  wounds  as  a  result  of  gunshot  and  stab  wounds 
and  fracture  of  the  pelvis. 

RUPTURE  OF  BLADDER. 

This  may  occur  as  a  result  of  either  violence  or  of  diseased 


RUPTURE  OF  THE  BLADDER.  207 

(and  weakened)  bladder  walls.     The  tear  is  usually  intraperitoneal. 

Symptoms. — The  first  symptom  is  sudden  pain  with  a  feeling 
as  though  something  had  broken  or  given  way  in  the  suprapubic 
region.  This  is  attended  with  a  desire  to  urinate  and  an  attempt 
to  empty  the  bladder  is  of  no  avail.  Unless  proper  measures  are 
employed,  the  patient  soon  passes  into  a  state  of  shock  and  death 
ensues  from  septic  peritonitis  or  pelvic  cellulitis.  If  the  urine  is 
sterile,  however,  efficient  measures  are  immediately  instituted;  the 
prognosis  is  more  favorable. 

Diagnosis. — The  patient's  personal  previous  and  present 
history  must  be  obtained.  Palpation  of  the  abdomen  and  rectal 
examination  will  usually  reveal  the  state  of  affairs  when  the  swelling 
is  in  Douglas'  cul-de-sac  and  adjacent  tissues.  A  reliable  test 
consists  in  passing  a  catheter  into  the  bladder,  injecting  a  known 
quantity  of  warm  sterile  salt  solution  and,  if  the  same  amount  is  not 
withdrawn,  the  deduction  is  accordingly  made.  Care  must  be 
taken,  however,  that  the  catheter  is  not  plugged  in  any  way.  The 
cystoscope  is  of  no  service  in  these  cases  owing  to  the  profuse  hem- 
orrhage. Exploratory  suprapubic  cystotomy  is  performed  when 
the  other  measures  fail  to  establish  a  correct  diagnosis. 

Treatment. — If  the  rupture  is  extra-peritoneal,  it  may  be  closed 
and  continuous  catheterization  employed  or  drainage  obtained 
through  the  suprapubic  opening,  and  the  prevesical  space  packed 
with  sterile  gauze  to  prevent  urinary  infiltration.  Absolute  cleanli- 
ness in  this  respect  is  imperative  and  any  evidences  of  burrowing 
or  suppuration  of  the  prevesical  space  or  perineum  should  be 
immediately  combated  by  free  drainage.  If  the  rent  is  intra- 
peritoneal, laparotomy  must  be  performed,  the  edges  of  the  tear 
closed  by  interrupted  sutures,  and  the  abdominal  wound  closed 
except  for  a  few  strips  of  gauze  drainage.  The  bladder  is  then 
drained  for  several  days  through  a  permanent  urethral  catheter  by 
means  of  which  it  may  be  frequently  irrigated. 

Foreign  bodies  often  gain  entrance  to  the  bladder  by  way  of  the 
urethra  or  through  its  walls  as  a  result  of  injury.  Cases  of  sexual 
perversion  are  frequently  met  with,  in  which  the  foreign  body  is 


2o8  AFFECTIONS    OF    THE    BLADDER. 

introduced  for  the  purpose  of  gratifying  their  sexual  cravings. 
The  ends  of  catheters,  filiforms,  etc.,  may  break  off  in  the  bladder. 
Bullets,  bits  of  shell,  pieces  of  clothing,  bone,  etc.,  may  enter  the 
bladder.  Solid  articles  which  were  swallowed  accidentally  have 
been  known  to  pass  from  the  intestines  to  the  bladder  by  ulcerations 
of  their  walls. 

Sjnnptoins. — As  the  article  soon  becomes  encrusted  with  deposits 
of  urinary  salts,  it  occasions  symptoms  practically  the  same  as 
calculi  in  the  bladder  (q.v.). 

Diagnosis  is  easily  made  by  means  of  the  stone  searcher  and 
the  cystoscope. 

Treatment. — Usually  a  small  suprapubic  opening  is  necessary 
in  extracting  the  foreign  body  unless  the  article  be  so  small  and 
brittle  that  it  may  sometimes  be  removed  by  means  of  a  lithotrite. 

TUBERCULOSIS  OF  THE  BLADDER. 

This  occurs  most  frequently  in  young  adults  between  15  aiid  40 
and  is  more  common  in  males  than  in  females.  The  mode  of 
infection  is  supposed  by  most  authorities  to  be  secondary  as  a 
result  of  extension  from  tuberculous  infiltration  from  the  seminal 
vesicles  or  prostate,  the  bacilli  being  conveyed  by  the  blood  current 
or  lymphatics  from  the  kidneys  or  testicle.  Primary  tubercle 
infection  of  the  bladder  is  rare. 

Pathology. — Tubercular  deposits  may  often  be  seen  early  by 
cystoscope  examination  in  the  form  of  minute  papules  or  pin  head 
sized  ulcerations  and  they  are  almost  invariably  found  around  the 
vesico-urethral  orifice  and  trigone  or  around  the  ureteral  openings. 
This  is  soon  followed  by  infection  from  the  micro-organisms  causing 
suppurative  cystites  and  frequently  ammoniacal  decomposition  of 
urine.  These  small  ulcerative  foci  later  in  the  disease  become  large 
and  irregular  and  covered  with  a  deposit  of  urinary  salts  and  slough- 
ing material  or  fungating  granulations  which  bleed  easily.  The 
bladder  walls  also  undergo  degenerative  changes  in  many  cases  and 
the  capacity  of  the  bladder  is  markedly  decreased.     As  the  process 


TUBERCULOSIS    OF    THE    BLADDER.  209 

continues  the  cellular  tissue  surrounding  the  base  of  the  bladder  is 
the  seat  of  abscesses  which  may  slough  and  form  fistulae  unless 
surgical  measures  are  adopted. 

Diagnosis. — Recognition  of  tubercle  infection  must  be  made 
by  urinary  examination  for  tubercle  bacilli  and  the  cystoscopic 
examination  of  the  bladder  mucous  membrane.  A  rectal  examina- 
tion is  also  necessary  to  ascertain  the  involvement  of  the  prostate 
and  seminal  vesicles.  The  patient's  personal  and  family  history 
must  also  be  noted. 

Prognosis  is  always  grave  in  these  cases  and  the  danger  of 
secondary  infection  of  the  kidneys  is  always  imminent.  Recovery 
from  tuberculosis  of  the  bladder  is  very  rare. 

Treatment. — In  the  incipiency  of  this  infection  attempt  should 
be  made  to  improve  the  vitality  of  the  tissues  and  check  the  ravages 
of  the  disease.  The  patient  should  if  possible  be  removed  to  a 
suitable  climate.  The  urine  should  be  kept  as  bland  as  possible. 
The  local  treatment  consists  in  careful  irrigations  of  the  bladder 
and  instillations  of  creosote  in  liquid  vaseline  (10  grs.  to  the  oz.)  or 
iodoform  emulsion.  Later  in  the  disease  when  the  pain  and  fre- 
quency of  urination  become  intolerable,  morphia  or  codeine  should 
be  given.  If  the  tenesmus  is  not  relieved  by  opiates  permanent 
suprapubic  drainage  through  a  fistula  is  advocated  by  many 
surgeons. 

The  use  of  silver  nitrate  instillations  or  irrigations  in  vesical 
tuberculosis  invariably  aggravates  the  condition.  This  fact  is  so 
constant  that  it  is  considered  a  positive  diagnostic  sign  in  all  cases  of 
cystitis  occurring  without  any  apparent  reason  and  where  no 
tubercle  bacilli  are  demonstrable. 

Bichloride  of  mercury  first  recommended  by  Guyon  is  probably 
the  best  local  remedy  we  have  for  tubercul^is  of  the  bladder.  It 
should  be  used  in  solution  of  i  :  loooo  to  i  :  5000  instilled  into  the 
bladder,  beginning  with  a  few  drams  and  gradually  increasing  it 
up  to  two  ounces,  but  never  enough  to  cause  distention.  This 
should  be  done  about  once  or  twice  a  week.     It  is  attended  with 


14 


216  AFFECTIONS    OF   THE   BLADDER. 

considerable  pain  in  the  beginning,  which  may  have  to  be  relieved 

by  morphia. 

Tenesmus  and  strangury,  which  are  noted  at  first,  soon  disappear 
as  the  condition  progresses  and  the  increased  strength  and  quantity 
of  the  instillation  are  well  borne  in  most  cases. 


CHAPTER  XI. 
AFFECTIONS  OF  THE  URETERS. 

The  ureters  may  be  double,  multiple,  or  entirely  absent;  they  may 
run  an  abnormal  course  and  in  some  cases  terminate  extravesically. 

The  shape  of  the  ureter  varies.  The  cahbre  is  not  uniform  but 
consists  of  a  series  of  constrictions  and  dilatations  thus  forming  a 
favorable  seat  of  lodgment  for  calculi. 

Tratwnatism. — Gunshot,  stab  wounds,  or  general  injuries  during 
surgical  operations  and  lacerations  by  unskilled  use  of  ureteral 
catheters. 

Treatment. — If  the  tube  is  more  or  less  severed  its  course  can  be 
re-established  by  anastomosis;  the  ureter  being  exposed  extra  or 
intra-peritoneally.     This  is  known  as  Van  Hook's  operation. 

Inflammation  of  the  ureters  or  ureteritis  is  caused  by  ascending 
or  descending  infection.  Stricture  of  the  ureters  may  also  occur 
and  may  be  treated  surgically  or  by  dilatation  with  bougies  by 
means  of  the  ureteral  cystoscopy 

Stone  in  the  ureter  may  become  impacted,  but  usually  after  a 
violent  renalcolic  it  passes  into  the  bladder. 

Diagnosis  of  ureteral  calculi  must  be  based  on  the  acute  onset 
of  the  renal  colic.  This  may  occlude  the  ureter  and  give  rise  to 
hydronephrosis  or  pyonephrosis.  Catheterization  will  as  a  rule 
ascertain  the  cause.  Kolischer  demonstrated  some  lo  years  ago 
that  impacted  calculi  can  be  liberated  from  its  incarceration  and 
brought  down  into  the  bladder  by  running  up  a  ureteral  catheter  to 
the  seat  of  the  impaction  and  by  subsequent  injection  of  sterile 
olive  oil. 

The  ureters  may  be  sounded  by  introducing  a  wax  tipped  ureteral 
catheter  (Kelly)  and  noting  the  scratches  made  by  the  stone.  The 
combination  of  X-ray  examination  and  ureteral  sounding  may  still 

211 


212  AFFECTIONS    OF    THE    URETERS. 

further  refine  the  diagnosis.  The  ureteral  catheter  is  armed  with  a 
"metalHc  stilletto  or  mandrin"  and  inserted  into  the  ureter,  the 
course  of  the  ureter  is  unmistakably  outlined  on  the  skiagram.  The 
relation  .of  the  tip  of  the  armed  catheter  to  the  shadow  of  the  stone 
will  determine  its  location. 

Treatment. — Hot  sitz  bath,  hot  rectal  irrigations,  and  morphia 
hypodermically.  The  bladder  should  be  emptied  by  the  patient 
or  catheterization  if  necessary.  If  the  stone  remains  impacted  it 
must  be  removed  surgically.  Where  it  is  loose  and  near  the  vesical 
outlet,  the  calculus  may  sometimes  be  removed,  through  an  operative 
cystoscope,  by  means  of  an  especially  devised  alligator  jaw  forceps. 


CHAPTER  XII. 

NEWER  AIDS  TO  DIAGNOSIS. 

THE  USE  OF  URETHROSCOPE. 

The  urethroscope  or  endoscope  which  was  first  introduced  by 
Nitze  has  attained  a  permanent  place  among  the  modern  instru- 
ments of  precision,  and  its  usefulness  in  aiding  the  diagnosis 
and  treatment  of  hitherto  obscure  and  remote  lesions  makes  it  a 
most  invaluable  adjunct  to  the  genito-urinary  armamentarium. 

The  instrument  used  for  the  anterior  urethra  may  be  described  as 
consisting  of  a  steel  tube,  ranging 'from  23  to  30  F.  in  calibre,  with 
an  obturator  or  stylet  as  it  is  sometimes  called.  The  electric  illumi- 
nation is  obtained  either  by  a  small  two  candlepower  lamp  inserted 
into  the  tube  almost  down  to  its  tip  or  the  light  may  be  reflected 
from  a  head  lamp  or  mirror  and  thus  the  condition  of  the  mucous 
membrane  at  the  end  of  the  tube  noted. 

The  pathological  appearances  of  chronic  urethritis  in  both 
the  anterior  and  posterior  urethra  may  be  clearly  revealed  to 
the  eye  without  the  least  harm  or  discomfort  to  the  patient.  In- 
filtrations, infection  of  the  follicles,  glands  of  Littre,  and  the 
lacuna  magna,  also  foreign  bodies  may  be  easily  detected.  The 
mucous  membrane  may  be  explored  thoroughly  almost  its  entire 
length  for  granular  and  congested  patches,  periurethral  thicken- 
ing, papillomata,  cedematous  folds,  foreign  bodies,  erosions,  etc. 
The  condition  of  the  verumontanum  may  also  be  noted  and  treated 
if  necessary  by  means  of  the  urethroscope. 

In  the  treatment  of  localized  area  of  infiltration,  congestion, 
etc.,  direct  application  thereto  is  greatly  facilitated,  thus  making 
it  an  extremely  useful  instrument.  A  number  of  urethroscopes  of 
different  manufacturers  are  on  the  market,  all  more  or  less,  modifi- 
cations of  the  other. 

213 


214  NEWER  AIDS    TO   DIAGNOSIS. 

Technic. — The  patient,  having  voided  the  urine,  is  placed  in 
a  recumbent  posture.  The  endoscopic  tube  or  canula  previously 
sterilized  is  lubricated  and  passed  carefully  into  the  urethra, 
traversing  the  entire  anterior  portion  of  the  canal.  The  stylet  is 
withdrawn  and  the  light  turned  on.  The  funnel  shape  aspect  of 
the  mucous  membrane  is  then  carefully  noted  along  its  entire  length 
as  the  operator  gradually  withdraws  the  instrument.  Any  morbid 
areas  can  be  touched  with  nitrate  of  silver  or  copper  sulphate  solu- 
tions (2  1/  2  to  10  gr.  to  the  oz.)  applied  by  means  of  a  cotton  applica- 
tor. Papillomata  may  be  seen  and  removed  sometimes  by  the  aid 
of  the  endoscope. 

CRYOSCOPY. 

Cryoscopy  is  employed  for  the  purpose  of  determining  the  molec- 
ular saturation  or  osmotic  pressure  of  fluids.  Koranyi,  who  was 
the  first  to  apply  cryoscopy  clinically,  has  attracted  considerable 
attention.  In  order  to  ascertain  the  significance  of  the  difference 
in  the  osmotic  pressure  of  the  blood  and  urine,  the  method  is  invalu- 
able as  a  test  for  renal  sufficiency,  and  is  therefore  useful  also  as  a 
guide  for  the  surgeon,  to  determine  the  competency  of  each  kidney 
separately,  when  used  in  conjunction  with  ureteral  catheters. 

The  utility  of  cryoscopy  depends  upon  ascertaining  the  following 
facts :  The  freezing  point  with  the  total  daily  amount  of  urine  allows 
us  to  differentiate  between  a  simple  albuminuria  and  albuminuria 
due  to  true  kidney  diseases. 

Normal  urine  freezes  between  — 1.2°  C.  and  —2.3°  C. 

The  freezing  point  of  urine  in  nephritis  is  always  higher  than 
normal. 

The  freezing  point  of  the  urine  from  the  well  kidney  is  lower  than 
from  the  diseased. 

The  freezing  point  of  the  blood  is  lower  than  that  of  the  urine  in 
nephritis. 

By  examination  of  the  total  amount,  it  is  possible  to  differentiate 
parenchymatous   and  interstitial   nephritis.     Also   between   acute 


CRYOSCOPY.  215 

and  chronic  forms  of  the  disease.  In  cystitis  or  pyelitis  if  the  freez- 
ing point  of  the  urine  shows  a  diminished  concentration,  it  may  be 
regarded  as  evidence  of  involvement  of  the  parenchyma  of  the  kid- 
neys. Concentration  of  the  urine  bears  a  definite  relationship  to  the 
character  and  amount  of  foods  taken.  It  is  also  influenced  by  the 
time  after  food  is  ingested,  concentration  being  greatest  after 
meals. 

Where  there  is  renal  incompetency  the  retention  in  the  blood  of 
substances  which  should  have  been  excreted  will  cause  an  increased 
molecular  concentration  of  the  blood.  Hence  the  freezing  point  of 
blood  falls  below  normal  when  symptoms  of  uraemia  arise. 

M.  Senator  confirms  the  results  of  Koranyi  and  thinks  that  the 
chlorides  are  less  abundant  where  there  is  a  slowed  circulation,  but 
the  molecular  concentration  is  increased. 

The  age  of  normal  individuals  has  no  influence  on  the  freezing 
point  of  blood.  In  normal  urine  the  higher  the  specific  gravity  the 
lower  the  freezing  point,  and  vice  versa. 

An  attack  of  uraemia  may  often  be  foretold  before  any  symptoms 
arise  by  means  of  cryoscopy,  employing  it  daily  during  the  course  of 
the  disease,  observing  the  freezing  point  of  both  blood  and  urine. 
By  it  we  can  differentiate  between  uraemic  coma  and  that  due  to 
cerebral  hemorrhage,  tumor,  alcoholism,  epilepsy,  opium  poisoning, 
and  hysteria.  Diabetic  coma,  however,  cannot  be  differentiated 
with  any  degree  of  certainty  and  therefore  must  be  aided  by  the 
phloridzin  test. 

As  an  aid  to  therapeutics,  uremia  may  sometimes  be  prevented 
by  the  early  administration  of  energetic  measures,  which  treatment 
can  be  instituted  earlier  than  otherwise  could  be  done.  It  will 
prove  the  efficiency  of  our  treatment  by  the  decreased  concentration 
of  the  blood  and  helps  to  determine  the  advisability  of  venesection 
and  transfusion  in  uraemia.  The  prognosis  may  be  more  accurately 
given,  if  we  observe  the  freezing  point  of  the  blood  and  urine.  If 
in  spite  of  our  treatment  the  freezing  point  of  blood  falls  and  that 
of  the  urine  rises,  the  prognosis  will  be  grave.  If  on  the  other  hand 
the  blood  shows  a  rise  and  the  freezing  point  of  the  urine  falls,  it 


2l6  NEWER  AIDS    TO   DIAGNOSIS. 

proves  that  our  efforts  in  the  treatment  have  been  successful  and  the 
prognosis  therefore  more  favorable. 

Casper  and  Richter  employ  both  blood  and  urine  in  their  work 
in  conjunction  with  the  methylene  blue  and  phloridzin  tests. 

The  steps  which  should  be  taken  by  the  surgeon,  in  making  an 
accurate  diagnosis,  previous  to  operations  on  the  kidney,  ac- 
cording to  Rumpel,  are  as  follows: 

1.  Cystoscopic  examination  of  the  bladder  and  ureteral  openings. 

2.  Ureteral  catheterization  (bilateral). 

3.  Cryoscopic  examination  of  the  separately  obtained  urines. 

4.  Cryoscopic  examination  of  the  blood. 

5.  Phloridzin  injection  and  estimation  of  the  excreted  sugar. 

6.  Methyl ene-blue  elimination  after  intramuscular  injection. 

A  chemic  and  microscopic  examination  should  supplement  the 
above  measures. 
The  apparatus  devised  by  Beckman  consists  of  the  following  parts: 

1.  A  glass  jar  5x7  ins.  fitted  with  a  metal  top,  having  four  open- 
ings for  the  tubes,  thermometers,  etc. 

2.  A  test-tube  6x1  1/2  ins.  known  as  the  ^'air  tube."  Inside  of 
this  is  fitted  the  tube  for  liquids,  having  a  side  arm,  known  as  the 
"inside  tube"  fitted  with  perforated  rubber  stoppers. 

3.  Standard  thermometer,  Heidenhain  model,  graduated  in  .01° 
C,  the  scale  registering  from  —.5°  C.  to  50°  C. 

4.  Small  thermometer  graduated  in  1°  C;  scale  from.— 10°  C, 
to  regulate  the  temperature  of  the  bath. 

5.  One  large  stirrer  for  salt  and  ice  mixture;  one  smaller  for 
liquid  to  be  frozen. 

6.  One  cooling  tube  for  cooling  liquids  before  freezing. 

The  glass  jar  is  nearly  filled  with  a  mixture  of  cracked  ice,  salt  and 
water,  and  the  parts  adjusted.  The  specimen  to  be  frozen  is  poured 
from  the  cooling  tube  into  the  inside  tube  (which  must  be  clean  and 
dry)  until  the  mercury  bulb  of  the  large  thermometer  is  immersed 
in  the  fluid.  The  tube  is  now  placed  in  the  "air  tube,"  constantly 
stirred  until  the  process  is  completed. 

If  blood  is  to  be  frozen,  it  is  obtained  from  one  of  the  superficial 


ROENTGEN    DIAGNOSIS    OF    LITHIASIS.  217 

veins  of  the  arm  in  the  usual  manner,  and  preferably  frozen  imme- 
diately but  may  be  safely  kept  on  ice  for  12  hours. 

The  TECHNic  is  most  important,  therefore  to  be  accurate  observe 
the  following  points: 

1.  Test  the  thermometer  before  using,  in  freezing  distilled  water 
which  should  freeze  at  the  zero  mark. 

2.  Stir  constantly  until  the  process  is  completed. 

3 .  The  mercury  bulb  of  the  thermometer  must  be  entirely  immersed 
in  the  fluid  to  be  frozen  and  must  not  touch  the  bottom  of  the  inside 
tube. 

4.  The  specimens  of  blood  and  urine  must  be  frozen  before  any 
decomposition  occurs. 

5.  Do  not  use  any  preservatives  in  the  specimen  to  be  examined. 

6.  Keep  the  tubes  well  corked  and  work  quickly. 

7.  The  temperature  of  the  bath  should  not  be  below  —2.5°  C. 
to  3.°  C. 

8.  The  inside  tube  must  be  absolutely  clean  and  dry  previous 
to  its  use. 

9.  Do  not  work  in  the  sunlight  or  where  there  are  draughts. 

ROENTGEN  DIAGNOSIS  OF  LITHIASIS  OF  THE  URINARY 

TRACT. 

Lumbar  exploration  and  similar  procedures  for  suspected 
nephrolithiasis  are  no  longer  in  order,  since  the  Roentgen  method 
not  only  shows  whether  or  not  any  calculi  are  present,  but  giving 
precise  information  as  to  their  size,  shape,  and  number.  It  will 
also  show  whether  there  are  any  calculi  in  the  ureter  or  bladder. 
The  X-ray  will  invariably  reveal  the  presence  of  renal  or  vesical 
calculi — provided  the  calculus  is  present. 

The  chemical  composition  of  the  calculi  of  the  urinary  tract 
determines  the  greater  or  lesser  depth  of  their  shadows.  The 
greater  their  atomic  weight,  the  greater  their  density  and  conse- 
quently the  more  distinct  shadows.  Thus  calculi  composed  of 
oxalate  of  lime  show  the  most  distinct  shadows.     Their  shadows  are 


2l8  NEWER  AIDS    TO   DIAGNOSIS. 

even  deeper  than  those  of  bone  tissue.  Next  to  them  we  find  those 
consisting  of  phosphate  of  lime,  while  the  uric  acid  calculi  give  the 
faintest  shadows. 

Calculi  are  not  of  one  distinct  type,  therefore  layers  of  various 
degrees  of  density  are  observed.  Two  types  are  generally  present, 
then  one  or  the  other  character  predominates.  It  frequently 
happens  that  there  is  a  nucleus  of  uric  acid  surrounded  by  alternate 
layers  of  the  other  elements.  This  explains  why  some  dense  areas 
are  found  in  all  cases  of  renal  calculus;  the  same  is  true  when  the 
calculi  are  of  small  size.  The  question  of  composition,  however,  is 
of  less  importance  than  that  of  bringing  the  calculous  area  as  near 
to  the  plate  as  possible,  and  keeping  the  field  absolutely  quiet. 

The  modern  skiagraphic  apparatus  consists  of  a  tubular  dia- 
phragm which  has  the  advantage  of  permitting  the  passage  of  only 
the  focal  rays,  and  showing  a  small  area  at  a  time.  A  general 
exposure  therefore  must  precede  that  of  a  limited  area.  The  time 
of  exposure  should  be  three  minutes  in  thin  and  five  or  six  minutes 
in  stout  individuals.  Usually,  the  longer  the  exposure  lasts  the 
clearer  will  the  bones  show  and  the  less  marked  will  be  the  calculi. 
The  same  general  principles  apply  to  the  skiagraphy  of  the  urinary 
bladder.  The  patient  should  be  in  a  recumbent  position,  and  the 
centre  of  the  tube  directed  to  the  upper  margin  of  the  symphysis. 
The  coccyx  should  show  well,  but  the  sacrum  gives  no  details.  An 
oblique  exposure  should  also  be  made,  as  it  may  show  whether  the 
stone  is  free  or  encysted.  For  showing  numbers  and  position  of 
calcuH  the  Roentgen  method  is  far  superior  to  the  cystoscope  and 
it  is  much  more  pleasant  for  the  patient.  Skiagraphy  of  the  renal 
regions  is  always  necessary  when  vesical  calculus  is  suspected,  be- 
cause there  is  often  found  a  renal  calculus  with  one  in  the  bladder. 
This  explains  the  common  recurrence  of  vesical  calculus  after  an 
operation. 

The  combination  of  X-ray  examination  and  ureteral  sounding 
is  another  step  in  refining  the  diagnosis.  If  a  ureteral  catheter 
armed  with  a  metallic  stiletto  or  mandrin  is  inserted  into  the  ureter, 
the  course  of  the  ureter  is  unmistakably  outlined  on  the  skiagram. 


CYSTOSCOPY   AND    URETERAL    CATHETERIZATION.  219 

The  advantages  of  the  appearance  of  this  shadow  on  the  X-ray 
picture  are  obvious.  The  relation  of  the  ureteral  shadow  to  that  of 
a  tumor  of  doubtful  nature  v^U  tell  whether  this  tumor  is  of  renal 
origin  and  if  the  shadows  of  supposed  ureteral  calculi  are  not  in 
intimate  connection  with  the  ureteral  shadow,  the  erroneous  diagnosis 
will  be  corrected.  The  relation  of  the  tip  of  the  armed  catheter  to 
the  shadow  of  a  renal  stone  v^U  determine  whether  the  stone  is 
lodged  in  the  renal  pelvis  or  in  the  parenchyma  of  the  kidney.  In 
plastic  operations  on  the  upper  end  of  the  ureter  or  on  the  renal 
pelvis,  a  ureteral  catheter,  inserted  previous  to  the  operation,  will, 
as  a  rule,  be  a  very  helpful  guide. 

CYSTOSCOPY  AND  URETERAL  CATHETERIZATION. 

The  direct  ocular  examination  of  the  interior  of  the  urinary  bladder 
by  means  of  the  cystoscope  was  first  placed  on  a  practical  and  gener- 
ally acceptable  basis  by  Nitze  and  is  now  one  of  the  firmly  established 
aids  in  surgery  for  exploration  and  diagnosis  of  the  bladder  and 
ureters  as  well  as  the  prognosis  and  treatment  of  pathological 
conditions  of  the  kidneys. 

Cystitis  has  become  classified  so  that  at  the  present  time,  des- 
quamative catarrh,  gonorrhoeal  cystitis,  tuberculous  cystitis,  and 
various  other  types  are  well  defined  in  their  pathological,  clinical, 
and  cystoscopic  characteristics.  The  knowledge  that  obstinate 
cystitis  might  be  obtained  by  torpid  ulcerations  is  one  of  the  achieve- 
of  cystoscopy.  We  get  information  as  to  the  relations  and  the  size 
of  the  growth.  The  cystoscope  will  usually  detect  a  vesical  calculus, 
and  at  the  same  time  vdll  give  full  formation  as  to  the  nature  of  the 
stone,  its  size  and  location,  and  whether  the  stone  is  free  or  par- 
tially encysted.  By  the  same  exploration,  the  condition  of  the 
bladder  wall  can  be  determined,  and  in  deciding  upon  the  choice  of 
operation,  it  is  also  a  valuable  aid. 

Cystoscopic  examination  will  furnish  information  in  prostatic 
disturbances.  The  surgeon  is  thereby  enabled  to  decide  intelli- 
gently upon  the  operation  to  employ  in  order  to  relieve  prostatic 
obstruction. 


220 


NEWER  AIDS    TO    DIAGNOSIS. 


Fig.  55- 


Fig.  s6. 


Fig.  57. 


Fig.  s8. 


Fig.  59. 


Fig.   6o. 


Fig.  6t. 


Fig.  62. 


Cystoscopic  Views. 


CYSTOSCOPY   AND    URETERAL    CATHETERIZATION. 


221 


The  cysloscopc  tells  whether  pus  or  blood  is  coming 
from  the  prostate  or  from  the  bladder  proper,  or 
whether  these  pathological  secretions  come  down  from 
the  kidneys.  Diverticula,  so  often  a  cause  of  great 
distress  to  the  patient,  can  be  successfully  removed 
after  having  been  diagnosed  through  the  cystoscopy 

Endovesical  operations  may  be  performed  through 
an  operative  cystoscope  and  applications  made  to 
ulcerative  lesions. 

The  condition  of  the  ureteral  orifices  can  be  ascer- 
tained. A  gaping,  or  injected  ureteral  mouth  indi- 
cates, almost  invariably,  some  pathological  condition 
in  the  kidney. 

Impacted  ureteral  calculi  have  been  seen  half- 
way out  of  the  ureteral  opening  and  the  operative 
cystoscope  relieved  this  condition. 

Beurger's  cysto-urethroscope  consists  of  a  sheath 
obturator  and  telescope.     The  sheath  is  proveded 
with  a  detachable  beak,  a  small  fenestra,   and  two 
irrigating  cocks.     The  source  of  illumination  in  the 
original  model  was  a  lamp  which  was  placed  just 
beyond  the  fenestra  and  which  shed  its  rays  through 
a  specially  constructed  prism,  in  such  a  manner  as 
to  transplant  the  origin  of  the  rays  to  a  point  in  the 
roof   of   the   sheath.     Recently  a  minute  lamp  has 
been  introduced  just  over  an  obliquely 
placed  frosted  window,  at  a  point  sur- 
mounting   the   fenestra    and    has    been 
found  to  give  even  more  brilliant  illumi- 
nation than  the  original  prismatic  form. 
Although  the  long  curved  beak  is  the  one 
that  is  most  useful,  a  short  tip  may  be 
substituted,  being  valuable  for  small  con- 
tracted bladders  and  for  use  in  the  fe- 
male.    The  telescope  is  furnished  with  a 


Fig.  63. — Buerger's  cysto- 
urethroscope  telescope  with 
endoscopic  knife  (used  for  cut- 
ting cysts)  attached. 


222 


NEWER  AIDS    TO   DIAGNOSIS. 


A 


'i 


W 


B 


Fig.  64. — (a)  Aspirator-injector  for  aspiration  of  the  fluid  in  the  sheath  before 
making  applications  without  telescope.  One  of  the  fine  canulae  may  be  used  for  in- 
jecting silver  nitrate,  the  other  for  observation,  (b)  Special  light  carrier  for  direct 
observation  with  lens  shutter,  (c)  Obturator,  (d)  Cysto-urethroscope  with  tele- 
scope in  place. 


CYSTOSCOPY  AND    URETERAL    CATHETERIZATION.  223 

specially  constructed  prism  which  gives  a  picture  that  is  deflected 
almost  90  degrees.  In  the  latest  models  this  prism  is  covered  with  a 
cylindrical  cap,  furnished  with  a  round  window  in  order  to  prevent 
the  reflexes  that  were  sometimes  produced  in  the  old  system.  At- 
tached to  the  inferior  surface  of  the  telescope  is  a  larger  groove,  which 
terminates  at  the  ocular  end  in  a  catheter  outlet.  This  channel  serves 
for  the  lodgment  of  a  catheter,  a  bougie  or  a  fulguration  wire,  or,  for 
the  handle  of  the  endoscopic  knife  that  shall  be  described  later  on. 
The  objective  end  of  the  catheter  groove  is  provided  with  two  fine 
cylindrical  sockets  for  the  reception  of  special  deflectors.  The 
deflectors  serve  to  guide  either  a  catheter,  bougie,  or  wire.  The 
telescope  is  fitted  eccentrically  in  the  sheath  and  hugs  the  roof, 
in  this  way  carrying  the  entrance  pupil  as  far  as  possible  from  the 
parts  to  be  seen.  We  have  here  a  telescopic  system,  which  gives  a 
moderately  magnified,  perfectly  illuminated,  and  reliable  upright 
picture  of  all  objects,  no  matter  how  close  to  the  telescope  they 
may  lie. 

Technic. — After  introduction  with  the  obturator  and  irrigation  of 
the  bladder  when  the  contents  are  turbid,  the  telescope  is  inserted 
and  an  irrigator  which  is  situated  about  three  feet  above  the  level 
of  the  table  is  attached  to  one  of  the  lateral  faucets.  The  other 
faucet  remains  closed  and  is  opened  in  order  to  empty  the  bladder. 
When  we  desire  to  bring  about  prolapse  of  the  urethral  mucous 
membrane,  irrigation  is  made  to  cease  temporarily,  or,  to  secure 
considerable  prolapse,  the  discharging  faucet  may  be  opened 
for  a  moment.  But  a  very  small  amount  of  fluid  is  allowed  to  enter 
the  bladder  and  we  begin  the  examination  of  the  empty  bladder 
noting,  if  we  wish,  the  peculiarities  of  the  case  in  hand.  The  flow 
is  then  again  started  and  allowed  to  continue  throughout  the 
examination,  only  being  made  to  stop  for  special  reasons,  or  while 
emptying  the  bladder.  If  we  do  not  care  to  study  the  collapsed 
bladder,  we  begin  the  search  for  the  ureters  which  are  usually  easily 
found  when  the  bladder  is  filled  with  but  a  small  amount  of  fluid, 
viz.,  from  30  to  100  c.c.  In  some  instances,  when  the  has  fond  is 
very  deep,  the  trigone  may  be  carried  far  downward  on  dilatation, 


224  NEWER  AIDS    TO   DIAGNOSIS. 

making  the  finding  of  the  ureters  more  difficult.  In  such  cases  it  is 
best  to  seek  the  ureteral  orifices  after  having  allowed  some  of  the 
fluid  to  run  out.  The  examination  of  the  trigone  is  next  in  order, 
and  during  this  step  it  is  best  to  raise  the  ocular  of  the  instrument 
so  as  to  bring  the  fenestra  fairly  close  to  the  mucous  membrane. 
The  scrutiny  of  the  sphincteric  margin  is  now  begun;  its  whole 
circumference  can  be  brought  into  view  by  simple  rotation  of  the 
shaft.  For  observation  of  the  juxta-sphincteris  portions  of  the  blad- 
der, we  should  have  little  fluid  in  the  bladder,  and  carry  the  shaft 
of  the  instrument  far  in  the  opposite  direction.  We  usually  examine 
the  floor  of  the  supramontane  and  montane  regions  next.  This 
accomplished,  the  fenestra  is  pused  into  the  bladder,  turned  up- 
ward and  withdrawn  for  the  examination  of  the  roof  and  side  walls 
of  the  supramontane,  montane  regions.  The  membraneous  urethra 
and  bulb  are  the  last  to  engage  our  attention.  Complete  rotation 
of  the  instrument  is  permissible  at  all  times  and  does  not  lead  to 
the  slightest  injury  of  the  urethra. 

Catheterization  and  sounding  of  the  ureters  has  become 
a  comparatively  simple  procedure.  A  sound  introduced  into 
the  ureter  will  give  information  as  to  the  patulence  of  this  tube; 
it  will  permit  one  to  locate  the  seat  of  an  obstruction.  The  scratches 
on  the  wax-tipped  catheter  of  Kelly  will  corroborate  the  presence  of 
ureteral  calculi.  Kolischer  first  demonstrated  that  an  impacted 
ureteral  stone  can  be  liberated  from  its  incarceration  and  brought 
down  into  the  bladder  by  running  up  a  ureteral  catheter  to  the  seat 
of  impaction  and  by  subsequent  injection  of  oil. 

The  combination  of  X-ray  examination  and  ureteral  sounding 
is  another  step  made  possible  by  cystoscopy.  (See  chapter  on 
X-ray  lithiasis.) 

In  plastic  operations  on  the  upper  end  of  the  ureter,  or  on  the 
renal  pelvis,  ureteral  catheterization  performed  previous  to  the 
operation  is  a  valuable  guide  to  the  surgeon. 

There  are  two  kinds  of  cystoscopes  that  are  of  particular  value, 
one  fitted  with  prismatic  lens,  the  other  with  direct  vision  lens. 
The  former  causes  an  inverted  image,  and  is  therefore  a  more  com- 


CYSTOSCOPY   AND    URETERAL    CATHETERIZATION. 


225 


plex  instrument.  Winfield  Ayres  has  devised  a  very  excellent 
cystoscope.  This  is  constructed  with  direct  vision  lens,  and  allows 
a  wide  view  of  the  bladder  wall  and  ureteral  openings. 


/  r-  \ 


Fig.    65. — Tilden- Brown    cystoscope.      (a)    Direct    lens    system,      (b)    Obturator    in 
position.      (c)    Retrograde   lens  system.      (d)    Direct  lens  system  in  position. 


The  telescope  and  catheter  tubes  are  made  in  one  portion  and 
are  independent  of  the  lamp  carrying  part,  and  fit  into  it  after  the 


15 


2  26  NEWER  AIDS    TO   DIAGNOSIS. 

mantle  is  removed.  After  the  instrument  is  passed,  the  bladder 
may  be  filled,  or  irrigated,  directly  through  the  barrel  of  the  cysto- 
scope. 

The  TECHNic  is  as  follows:  The  instrument  should  be  steri- 
lized by  immersing  it  for  five  minutes  in  a  solution  of  mercury  oxy- 
cyanide  i  to  looo,  or  formalin  i  to  500.  The  mercury  oxy cyanide 
solution  is  preferable  to  the  formalin,  as  it  is  non-irritating  to  the 
hands,  or  to  the  mucous  membranes,  and  has  no  deteriorating  action 
on  metal  instruments  or  on  the  ureteral  catheters.  In  the  male, 
the  glans  penis  should  be  rendered  sterile,  and  the  same  care  exer- 
cised in  the  female,  by  cleansing  the  vulva  and  urethral  orifice. 
The  hands  of  the  operator  should  also  be  sterilized. 

The  patient  is  placed  upon  the  table  in  the  lithotomy  position  with 
the  hips  slightly  elevated,  to  prevent  the  fluid  escaping  from  the 
bladder  along  the  side  of  the  instrument.  The  lamp  should  always 
be  tested  just  before  using  it.  The  instrument  is  now  taken  and 
well  lubricated  with  lubrichondrin  or  any  other  soluble  lubricant, 
and  passed  gently  into  the  urethra,  as  one  does  with  an  ordinary 
sound,  until  the  prostatic  urethra  is  reached,  when  owing  to  the 
short  beak,  the  outer  end  of  the  instrument  must  be  brought  well 
down  between  the  thighs,  which  will  allow  it  to  enter  the  bladder 
easily.  The  canula  is  now  withdrawn,  and  the  bladder  filled 
directly  through  the  barrel  with  oxycyanide  solution  i  to  5000,  and 
about  8  to  10  ounces  left  in  the  bladder  during  the  examination. 
The  telescope  and  catheters  are  inserted,  the  current  turned  on,  and 
the  bladder  illuminated.  The  instrument  should  be  tilted  carefully 
in  all  directions;  drawn  slowly  back  and  forth,  when  the  ureteral 
orifices  will  usually  appear  as  small  oblique  slits,  cavities,  or  small 
papular  prominences,  or  sometimes  they  cannot  be  readily  seen 
until  they  emit  a  spurt  of  urine.  When  located  the  catheters  are 
carefully  inserted  and  gently  pushed  upward  until  the  tip  is  in  the 
pelvis  of  the  kidney.  Should  the  urine  fail  to  flow,  it  may  simply  be 
due  to  a  small  bubble  of  air  in  the  catheter.  This  may  usually  be 
expelled  by  the  patient  giving  a  few  violent  coughs,  which  will  start 
the  flow  of  urine. 


CYSTOSCOPY  AND    URETERAL    CATHETERIZATION.         227 

The  instrument  may  now  be  removed  and  the  catheters  left  in 
place,  thus  allowing  the  urine  to  be  drawn  from  the  separate  kidneys, 
which  is  collected  in  two  sterilized  bottles  for  the  purpose  of  micro- 
scopic examination  and  chemic  analysis.  If  the  catheters  are  of 
two  different  colors,  it  can  be  readily  discerned  which  drains  the 
right  and  which  the  left  kidney. 

Inflammatory  conditions  of  the  ureters  may  be  diagnosticated 
from  the  microscopic  findings.  Catarrhal  pyelitis  is  evidenced 
when  the  microscope  shows  epithelial  cells  from  the  renal  pelvis, 
either  superficial  or  deep,  with  the  presence  of  little  or  no  pus  and 
mucus.  Purulent  inflammations  of  the  kidney  may  also  be 
differentiated. 

Lavage  treatment  of  lesions  in  the  pelvis  of  the  kidney,  through 
the  ureteral  catheter,  is  now  practised  by  many  surgeons  with  good 
results.  A  glass  syringe  of  about  100  c.c.  capacity  is  fitted  with  a 
needle  which  will  pass  into  the  end  of  the  catheter ;  then  with  gentle 
pressure  not  more  than  5  or  10  c.c.  should  be  injected  at  a  time 
and  this  allowed  to  run  out  before  it  is  repeated.  If  a  larger  amount 
is  given  there  is  danger  of  it  causing  considerable  pain,  but  after  a 
few  treatments  the  amount  can  be  gradually  increased.  Should 
the  injection  give  rise  to  the  least  pain,  the  pelvis  must  be  allowed 
to  empty  itself  immediately,  before  repeating  the  injection. 

A  solution  of  i  to  8000  of  silver  nitrate  in  a  saturated  solution  of 
boric  acid  should  be  used  at  the  first  treatment,  but  the  strength  may 
be  gradually  increased  up  to  i  to  2000  or  even  i  to  1000  in  successive 
treatments.  In  purulent  cases  it  may  be  used  much  stronger,  from 
I  to  1000,  to  I  to  500.  These  solutions  should  be  given  at  the 
temperature  of  about  100  F.  Upon  withdrawing  the  catheters  the 
injection  is  continued,  irrigating  the  entire  length  of  the  ureters. 
After  the  patient  has  emptied  his  bladder,  the  urethra  and  bladder 
should  be  irrigated  with  a  solution  of  silver  nitrate  about  i  to  5000 
in  strength.  Strictures  of  the  ureters  are  occasionally  met  by  the 
failure  of  ordinary  sized  catheter  to  pass  upward  into  the  pelvis. 
No.  4  or  5,  French,  is  about  the  proper  size  to  use.  It  must  be 
remembered  that  the  lumen  of  the  ureter  is  slightly  constricted  at 


228  NEWER  AIDS    TO    DIAGNOSIS. 

three  points;  a  muscular  constricture  at  the  entrance  of  the  bladder; 
another  where  the  ureter  passes  over  the  brim  of  the  pelvis;  and  a 
distinct  narrowing  about  an  inch  from  the  pelvis  of  the  kidney. 

Mythylene  blue  has  also  been  used  as  a  test  to  depend  on  coloring 
matter  seen  coming  from  the  ureters  by  means  of  the  cystoscope, 
but  has  been  found  to  be  of  very  little  value.  The  objections  being 
the  inconstancy  of  color  reaction  and  the  occasional  elimination  of 
methylene  blue  as  colorless  chromogen. 

Phloridizin  Test. — The  use  of  phloridzin  in  testing  the  func- 
tional activity  of  a  suspected  diseased  kidney  was  first  employed  by 
Klemperer.  The  method  consists  in  a  subcutaneous  injection  of 
0.005  g^-  ^f  phloridzin  which  produces  a  temporary  glycosuria 
depending  for  its  amount  upon  the  activity  of  the  renal  parenchyma. 
The  secretion  from,  each  kidney  is  collected  separately  by  means  of 
ureteral  catheterization.  The  changes  in  each  are  noted  and  the 
amount  of  sugar  contained  in  the  separate  urine  is  compared. 

The  urine  segregator  is  another  useful  aid  to  diagnosis,  but  its 
field  of  application  is  more  limited  than  that  of  the  cystoscope. 
There  are  several  kinds  of  segregators,  the  best  of  which  are  the 
Harris  and  the  Cathelin  instruments.  The  Harris  instrument  raises 
the  posterior  wall  of  the  bladder  into  a  longitudinal  fold  forming  a 
water  shed  between  the  ureteral  orifice,  whereas  the  Cathelin  segre- 
gator attempts  to  form  a  water-tight  septum  within  the  bladder, 
but  when  the  viscus  is  empty,  a  water-tight  partition  is  practically 
impossible,  omng  to  the  folds  in  the  mucous  membrane. 

The  use  of  the  segregator  is  only  indicated  where  the  diagnosis  of 
renal  impairment  is  desired,  and  not  to  be  used  in  cases  of  diseased 
bladder.  A  cystoscopic  examination  therefore  should  always  precede 
an  attempt  to  segregate  the  urines. 

Indigo-carmin  test  consists  of  a  hypodermic  injection  of  in- 
digo of  indigocarmine  (0.6  gm.  dissolved  in  normal  salt  solution) 
into  the  gluteal  muscle.  It  is  an  easy  and  reliable  method  of  the 
functional  activity  of  the  kidneys.  In  the  normal  kidney,  the  urine 
is  stained  in  ten  or  twelve  minutes  after  the  injection.  If.  however, 
only  a  green  color  appears  and  does  not  become  intensified,  or  any 


CYSTOSCOPY   AND    URETERAL    CATHETERIZATION.  229 

undue  delay  occurs  in  making  its  appearance,  there  is  some  functional 
derangement. 

Phenolsulphonephthalein  test,  according  to  Rowntree  and 
Geraghty,  is  said  to  possess  the  following  advantages: 

1.  The  complete  elimination  of  the  drug  by  the  kidneys,  its 
chemical  nature  being  unchanged. 

2.  The  early  appearance  of  the  drug  in  the  urine  following  its 
administration. 

3.  The  rapid  excretion  of  the  drug  by  the  kidneys,  necessitating 
observation  over  only  a  short  time — one  or  two  hours. 

4.  The  brilliancy  of  color  which  is  imparted  to  alkaline  urine  and 
which  is  not  readily  influenced  by  the  coloring-matter  of  the  urine 
itself. 

5.  The  facility  with  which  this  drug  lends  itself  to  colorimetric 
methods,  making  accurate  quantitative  estimations  possible. 

6.  The  simplicity  of  the  technic  for  quantitative  estimation. 

7.  The  absolute  non- toxicity  of  the  drug. 

8.  The  non-irritant  nature  of  the  drug  locally. 

9.  The  extreme  smallness  of  the  dose  required  and  the  assurance 
this  gives  of  there  being  no  extra  strain  placed  upon  the  kidney 
during  the  test. 

Because  of  its  extreme  delicacy  and  simplicity  is  the  most  satis- 
factory test  we  have  for  testing  the  renal  function.  Pilcher  describes 
the  technic  practically  as  follows: 

Technic. — About  a  half  hour  before  the  test,  the  patient  should 
drink  two  or  three  glasses  of  water;  6  mg.  of  phenolsulphonephthalein 
is  added  to  i  c.c.  of  normal  salt  solution,  sterilized  by  boiling 
and  injected  hypodermatically,  and  the  water  catheterized.  Place 
4  c.c.  of  25  per  cent.  NaOH  in  each  test-tube  and  allow  the  catheter 
to  drain  into  the  alkaline  solution.  As  the  first  trace  of  the  drug 
appears  in  the  urine  (5  to  12  seconds  in  normal  kidneys),  pinkish 
color  will  be  observed,  which  grows  in  intensity  as  the  urine  increases. 
It  can  be  detached  in  a  single  drop  of  urine.  In  an  acid  urine,  the 
color  is  a  deep  yellow.  In  a  strong  alkaline  solution,  the  color  is 
purple,  reaching  its  maximum  in  30  minutes. 


CHAPTER  XIIL 
THE    CHANCROID. 

Synonyms. — It  has  been  variously  termed  soft  chancre,  non- 
infecting   sore,  simple,    non-indurated,    or   non-syphilitic   chancre. 

Definition. — The  chancroid  is  a  simple  infectious  ulcer  due 
to  the  streptobacillus  of  Ducrey,  occurring  usually  on  or  about  the 
genitalia.  It  is  destructive  in  its  tendencies  but  under  ordinary 
circumstances  is  a  cutaneous  lesion  involving  the  superficial  struc- 
tures only,  and  is  not  followed  by  any  constitutional  manifestations. 

Its  secretion  is  purulent  in  character,  highly  infectious,  and  is 
usually  the  vehicle  of  chancroidal  contagion.  An  interesting  feature 
is  that  the  chancroid  is  auto-inoculable,  and  that  animals  are  not 
immune  to  it. 

The  mode  of  infection  is  generally  from  contact,  which  occurs 
most  often  in  the  act  of  coitus.  It  is  acquired,  therefore,  by  direct 
contagion,  and  very  rarely  in  any  other  way.  The  seat  of  the  inocu- 
lation is  favored  by  a  loss  of  continuity  in  the  tissues,  e.g.,  an  abra- 
sion, chafes,  erosions,  herpes,  etc. 

The  chancroid  is  distinctly  venereal,  hence,  its  source  of  origin 
is  easily  assigned.  It  often  begins  as  a  simple  inflammatory  lesion, 
which  very  soon  becomes  the  seat  of  pyogenic  infection,  resulting 
in  a  typical  septic  ulcer.  The  lymphatic  glands  in  intimate  anatom- 
ical relation  to  the  chancroid  are  very  frequently  involved,  resulting 
in  the  so-called  chancroidal  huho.  When  there  is  a  co-existent 
initial  lesion  the  sore  becomes  a  favorable  nidus  for  pyogenic  in- 
vasion. This  condition  is  then  known  as  the  mixed  chancre  or 
mixed  infection. 

The  BACTERIOLOGY  of  the  chancroid  has  made  decided  advance 
toward  discovering  the  causal  factor.  But  even  at  the  best  it  is 
still  indefinite.     Much  credence  has  been  placed  in  the  claims  of 

230 


PERIOD    OF    INCUBATION.  23 1 

Ducrey  and  Unna  who  claim  to  have  succeeded  in  isolating  the 
specific  micro-organism  which  is  known  as  the  streptobacillus  of 
Ducrey-Unna.  These  organisms  have  been  found  in  both  the  pus 
and  the  tissue  of  chancroids  and  also  from  accompanying  buboes. 
The  culture  media  used  was  im coagulated  rabbit's  blood  serum, 
and  later  blood  agar. 

Site. — The  inner  integument  of  the  mucous  membrane  of  the  pre- 
puce is  most  commonly  the  seat  of  chancroids,  but  they  may  be  seen 
on  any  portion  of  the  genitalia,  e.g.,  corona  sulcus,  frenum,  shaft 
of  penis,  lips  of  meatus  (rare),  and  when  from  auto-inoculation,  it 
may  occur  on  the  scrotum,  thighs,  pubis,  and  anus. 

In  females  they  are  most  commonly  found  on  the  fourchette, 
vestibule,  clitoris,  labia  minora,  labia  majora,  on  the  os  uteri,  and 
when  from  auto-inoculation,  upon  the  perineum,  thighs,  and  pubis; 
and  sometimes  the  anus.  Chancroids  of  the  vagina  and  os  uteri 
are  very  rare,  but  may  be  occasionally  found. 

Varieties. — Single,  multiple,  phagedenic,  and  serpiginous. 

Complications  may  be  phimosis,  paraphimosis,  lymphangitis, 
lymphadenitis  (bubo),  vegetations,  phagedena,  gangrene,  mixed 
infection,  balanitis,  and  balano-posthitis. 

The  peroid  of  incubation  of  chancroids  is  one  to  seven  days 
mth  an  average  of  twenty-four  to  forty-eight  hours. 

Inflammatory  symptoms  at  the  point  of  the  inoculation  begin  very 
early.  Usually  within  twenty-four  hours  a  pustule  appears  which 
in  one  or  two  days  will  be  seen  to  have  a  distinct  red  areola  surround- 
ing its  base.  Within  a  week  this  undergoes  ulcerative  changes,  the 
discharge  is  purulent,  the  sore  painful,  but  has  no  indurated  base. 
The  outline  of  the  ulcer  may  be  round  or  oval,  even  or  irregular. 
Its  base  paunched  out  in  appearance,  the  floor  being  uneven,  and 
covered  with  a  pseudo-membrane. 

The  duration  is  indefinite  and  depends  largely  upon  the  treat- 
ment, hygiene,  and  habits  of  the  patient. 

The  conditions  which  are  commonly  confounded  in  making  a 
diagnosis  of  chancroids  are:  chancre,  herpes,  eczema,  balanitis, 
simple  ulcers,  abrasions,  or  excoriations.     Chancroid  may  be  dis- 


232 


THE    CHANCROID. 


tinguished  from  chancre  by  its  rapid  development,  its  situation, 
character  of  the  secretion,  absence  of  induration,  period  of  incuba- 
tion, and  its  tendency  to  multiplicity. 

DIFFERENTIAL  DIAGNOSIS  OF  CHANCROID  AND 

CHANCRE. 


Chancre. 

Lesion  of  a  constitutional  disease. 
First  stage  of  syphilis. 

Due  to  syphilitic  infection,  may  be 
by  contact  ^Yith  chancre. 

May  occur  on  any  part  of  the  body. 

Period  of  incubation  from  lo  days 
to  ID  weeks  (usually  3  weeks  is  an 
average) . 

Base  indurated. 

Little  inflammation  around  sore. 

Nearly  always  single. 

It  is  inoculable  but  not  auto-inocu- 
lable,  except  in  mixed  infection. 

Secretion  thin  and  scant}^  unless 
irritated. 

Sore  is  attended  with  little  or  no 
pain. 

Edges  sloping  and  not  undermined. 

Polyganglionic  bubo,  painless  (rarely 
suppurates).  Never  furnishes  in- 
oculable pus. 

Scanty  serous  secretion. 

Begins  as  papules. 

Tendency  to  heal  rapidly. 

Phagedena  is  very  rarely  seen. 

Presence  of  spirochaeta  pallida. 


Chancroid. 

Local  disease,  not  followed  by 
secondary  symptoms. 

Due  to  contact  with  secretions  of 
sore  of  same  nature  (chancroid). 

Nearly  always  occurs  on  genitals, 
rarely  extra-genital. 

Period  of  incubation  less  than  10 
days. 

Base  not  indurated  as  a  rule,  unless 
deeply  cauterized  or  irritated. 

Considerable  inflammation  around 
sore. 

Generally  multiple. 

Auto-inoculable. 

Secretion  purulent  and  profuse, 
hemorrhagic  and  often  offensive  in 
odor. 

Sore  is  painful. 

Edges  undermined. 

Monoganghonic,  painful  bubo, 
which  suppurates,  forming  inoculable 
pus. 

Copious  purulent  secretion. 

Begins  as  pustules. 

Tendency  to  spread. 

In  chancroid  phagedena  occurs  fre- 
quently in  neglected  cases. 

Presence  of  strep  tobacillus  of 
Ducrev. 


CHANCROIDAL   BUBO.  233 

From  HERPES  chancroid  may  be  recognized  by  the  former  usually 
appearing  on  the  glans,  penis,  and  prepuce,  as  small  vesicles  occur- 
ring in  groups,  setting  closely  together,  light  in  color,  and  resting 
on  a  florid  base.  In  eczema  these  vesicles  are  more  minute  and 
diffused  than  in  herpes.  There  is  generally  greater  local  irritation, 
the  parts  being  swollen  and  painful,  itching  and  burning. 

In  BALANITIS  the  inflammation  is  usually  widely  diffused,  the 
discharge  very  profuse,  and  the  involvement  is  not  circumscribed. 

CHANCROIDAL  BUBO. 

Strictly  speaking  the  bubo  simply  consists  of  an  adenitis  or 
lymphangitis  occurring  from  any  cause,  but  clinically  it  is  restricted 
to  an  inflammation  of  the  inguinal  ganglia  and  perivascular  tissues 
which  accompanies  a  venereal  sore  or  gonorrhoea.  It  may,  however, 
occur  from  any  irritating  or  suppurating  process  on  any  part  of  the 
lower  extremities.  Chancroidal  bubo  is  an  enlargement  of  the 
inguinal  or  crural  lymphatic  glands  (or  both)  and  usually  occurs 
during  the  existence  of  the  lesion,  as  a  result  of  absorption  of  its 
poisonous  secretion. 

The  symptoms  are  at  first  inflammatory;  with  tenderness,  pain, 
swelling,  and  discoloration.  Later  the  process  undergoes  typical 
abscess  formation  or  suppuration. 

Chancroidal  bubo  usually  occurs  on  the  same  side  as  the  sore, 
and  is  as  a  rule  limited  to  one,  but  sometimes,  though  seldom,  it 
involves  two  glands,  rarely  more.  It  runs  its  course  rapidly  and 
may  or  may  not  be  accompanied  with  constitutional  disturbances. 
Should  the  suppurating  condition  result  in  sloughing  of  its  covering, 
it  is  referred  to  as  an  ulcerating  bubo. 

Indolent  bubo  occurs  in  persons  of  debilitated  and  scrofulous 
constitution.  After  having  made  a  certain  amount  of  progress,  the 
enlarged  glands  may  remain  stationary  for  some  time,  neither 
advancing  nor  receding.  Sooner  or  later  resolution  or  suppuration 
occurs. 


234 


THE   CHANCROID. 


SYPHILITIC  BUBO. 

As  a  rule  involves  several  glands. 

Most  commonly  bilateral  or  sym- 
metrical. 

Usually  occurs  soon  after  the  lesion 
appears. 

In  size  the  glands  are  about  as  large 
as  a  pea  or  a  little  larger. 

Inflammatory  symptoms  not  present 
in  uncomplicated  cases. 

Rarely  suppurates  save  in  mixed 
infection. 

Pain  and  tenderness  will  be  absent 
or  less  severe. 


CHANCROIDAL  BUBO. 

Usually  involves  one  gland,  rarely 
more  than  two. 

May  be  bilateral  but  more  com- 
monly unilateral. 

May  occur  at  any  time  during  the 
existence  of  the  lesion  or  soon  after 
healing. 

Vary  in  size  may  become  large  as  a 
lemon. 

Inflammatory  symptoms  are 
marked. 

Usually  terminates  in  suppuration. 

Pain  and  tenderness  often  well 
marked. 


Treatment  of  Buboes. — Where  there  is  a  simple  adenitis,  reso- 
lution might  be  induced  by  the  patient  being  put  at  rest  in  a  recum- 
bent posture,  and  the  application  of  hot  or  cold  fomentations,  and 
lead  water  and  laudanum  to  the  part.  Firm  compression  of  the 
groin  with  a  spica-bandage  is  often  efficient.  Sometimes  counter- 
irritants  such  as  tincture  of  iodine  applications  will  be  found 
beneficial. 

Abortive  Methods. — In  the  early  stage  of  inflammatory  buboes, 
Horwitz  advocates  interstitial  hypodermic  injections  of  carbolic  acid 
solution  (8  gr.  to  the  oz.)  injecting  about  1/2  drachm  into  different 
portions  of  the  glandular  substance.  The  effect  is  then  further 
enhanced  by  firm  compression  with  a  gauze  pad  held  in  place  by  a 
spica-bandage,  and  the  patient  put  at  rest.  Should  these  measures 
fail  and  there  are  distinct  signs  of  fluctuation  present,  indicating  the 
presence  of  pus,  the  part  should  be  shaved  and  rendered  aseptic.  A 
small  incision  about  1/4  of  an  inch  in  length  is  made,  and  the  pus 
evacuated.  The  abscess  cavity  should  then  be  washed  out  with 
sublimate  solution  (1-5000),  introduced  by  means  of  a  hand  syringe, 
and  then  one  or  two  syringefuls  of  peroxide  of  hydrogen  injected. 


TREATMENT.  235 

This  is  again  followed  by  the  sublimate  washings  until  the  solution 
comes  away  clean.  An  ointment  consisting  of  10  per  cent,  solution 
of  iodoform  in  vaseline  is  softened  by  heat  and  drawn  into  a  syringe 
and  injected  until  the  abscess  cavity  is  filled.  This  is  congealed  by 
holding  a  piece  of  ice  over  the  mass.  The  opening  is  then  closed 
with  a  thin  layer  of  absorbent  cotton,  held  in  place  by  collodion. 
The  groin  may  be  bandaged  and  the  patient  kept  at  rest  in  bed  for 
the  first  few  days.  It  is  well  to  advise  continuing  with  ice  over  the 
part,  keeping  the  iodoform  ointment  constantly  caked,  and  inci- 
dently  promoting  resolution. 

Should  the  suppurating  process  still  persist,  radical  operative 
TREATMENT  is  the  Only  effective  means  of  its  termination.  This  con- 
sists in  making  a  free  incision  over  the  affected  area  which  has  been 
previously  rendered  sterile,  followed  by  a  partial  or  complete  exci- 
sion of  the  diseased  glands  and  a  curettement  of  the  surface,  and 
then  touching  the  floor  of  the  cavity  with  carbolic  acid,  packing  it 
with  iodoform  gauze,  and  allowing  it  to  heal  by  granulation.  Sub- 
sequent treatment  of  the  wound  consists  of  bichloride  irrigations 
(1-5000)  and  stimulated  with  dressings  of  balsam  of  peru  gauze,  or 
ointment.     The  formula  of  the  latter  is  as  follows: 

I^      Balsam  peru 5i 

Calomel 5ii 

Ung.  zinci  oxidi  q.  s.  ad §i 

The  formation  of  any  exuberant  granulations  should  be  com- 
bated by  applications  of  nitrate  of  silver  pencil.  The  wound  should 
be  dressed  daily  until  granulations  have  begun,  and  then  dressed 
every  other  day. 

TREATMENT  OF  CHANCROID. 

This  must  naturally  depend  on  the  character  of  the  lesion, 
but  the  principles,  and  the  general  management  of  the  various 
conditions,  remain  practically  the  same.  First  of  all  the  insistence 
of  absolute  cleanliness  on  the  part  of  the  patient  is  necessary.  This 
is  best  accomplished  by  prescribing  frequent  baths  or  washings  of 


236  THE    CHANCROID. 

the  part  with  tincture  of  green  soap  and  warm  water,  then  immersing 
it  in  either  warm  normal  salt  solution,  potassium  permanganate 
(1-3000),  bichloride  (1-3000),  or  boric  acid.  In  fact  any  of  the 
mild  antiseptics  may  be  used  for  this  purpose.  The  sore  should 
then  be  sprayed  with  peroxide  of  hydrogen,  so  as  to  disintegrate 
the  desiccated  blood  and  pus.  In  patients  where  the  chancroidal 
ulcer  remains  localized  and  superficial,  with  a  thin  purulent  film 
covering  its  floor,  the  treatment  must  be  directed  at  first  to  destroy- 
ing the  covering,  by  the  use  of  carbolic  acid  gently  applied  over  the 
area  with  a  small  piece  of  absorbent  cotton  wrapped  around  the 
end  of  a  tooth-pick  or  wire  applicator.  Nitric  acid  (25  or  50  per 
cent.)  may  also  be  used,  or  the  acid  nitrate  of  mercury  solution 
(i-io).  Previous  to  the  application  of  either  of  these  two  agents, 
it  is  best  to  anaesthetize  the  area  with  a  solution  of  cocaine  as  strong 
as  10  per  cent,  freshly  made.  Nitrate  of  silver  should  never  be 
used  on  any  venereal  lesion,  by  reason  of  the  area  of  induration  it 
usually  produces.  But  if  a  stimulating  effect  is  desired,  a  2  or  3 
per  cent,  solution  of  copper  sulphate  answers  this  purpose  admir- 
ably. Should  the  floor  of  the  ulcer  then  appear  clean  and  covered 
with  healthy  granulations,  cauterizations  should  be  abandoned  and 
the  ordinary  stimulating  lotions  or  dusting  powders  used.  Should 
complications  develop  they  must  be  treated  accordingly.  If 
there  be  much  oedema,  a  gauze  dressing  saturated  with  lead  water 
and  laudanum  and  wrapped  around  the  part  will  be  usually  found 
effective.  The  treatment  of  these  lesions  when  occurring  in  the 
female,  is  practically  the  same.  It  is  always  well  to  interpose  some 
absorbent  cotton,  preventing  the  healthy  parts  from  coming  in 
contact.  Probably  the  most  efficient  all  around  dressing  tt)  ordinary 
chancroids  is  black  wash  (Lotio  Nigre)  applied  on  a  thin  film  of 
cotton  and  kept  continuously  moist.  Where  the  lesion  presents 
more  virulent  tendencies,  iodoform  is  the  agent  par  excellence. 
Both  these  have  the  combined  effect  of  sedative  and  stimulating 
properties.  The  iodoform  may  be  combined  with  sub-nitrate  of 
bismuth,  boric  acid,  etc.  Curettement  of  chancroid  is  sometimes 
indicated  when  its  tendency  is  to  become  serpiginous  and  obstinate. 


TREATMENT.  237 

The  local  treatmekt  of  phagedenic  chancroids  must  be 
supplemented  by  tonic  stimulants,  and  the  pain  relieved  by  opiates. 
The  phagedenic  process  must  be  checked.  Sometimes  it  will  be 
necessary  to  resort  to  the  curette,  afterward  touching  the  base 
with  nitric  acid  or  the  actual  cautery.  If  its  situation  is  subpre- 
putial  and  is  attended  with  phimosis,  it  must  be  rendered  accessible 
by  an  immediate  dorsal  incision  of  the  overlying  tissues  extending 
back  as  far  as  the  sulcus  on  the  median  line. 

The  treatment  of  chancroidal  paraphimosis  consists  in 
either  attempting  to  reduce  the  retracted  prepuce  manually.  Where 
this  fails,  surgical  intervention  is  urgently  necessary.  The  constrict- 
ing ring  must  be  completely  divided  to  relieve  the  strangulation. 
This  incision  is  also  made  in  the  median  line  on  the  dorsal  surface 
(see  chapter  on  phimosis  and  paraphimosis). 


CHAPTER  XIV. 
SYPHILIS. 

Synonyms:     Lues  venera;  pox;  morbus  gallicus,  etc. 

Definition. — Syphilis  is  a  general  chronic  infectious  disease, 
due  to  the  spirochaeta  pallida  affecting  the  entire  economy,  character- 
ized by  local  manifestations  and  adenopathy.  It  is  classed  with 
the  infectious  granulomata  such  as  tuberculosis,  glanders,  and 
leprosy. 

General  Considerations. — Syphilis  begins  as  a  local  lesion  at 
the  point  where  the  virus  has  gained  entrance  to  the  system  through 
contact,  which  medium  may  be  direct  or  indirect  with  a  syphilitic 
person.  In  its  incipiency,  or  the  first  period  of  incubation  of  syphilis, 
there  may  or  may  not  be  constitutional  disturbances,  e.g.,  rigors, 
fevers,  malaise,  anorexia,  anaemia,  headaches,  rheumatoid  pains, 
and  albuminuria.  These  morbid  phenomena  together  with  cu- 
taneous eruption  strongly  resemble  the  exanthemata,  particularly 
diphtheria  and  small-pox. 

The  two  forms  of  syphilitic  infection  are:  the  acquired  and 
hereditary  forms. 

Acquired  syphilis  begins  as  a  local  lesion  or  the  chancre,  but  in 
hereditary  syphilis,  there  is  no  initial  lesion,  the  disease  beginning 
with  general  manifestations.  Syphilis  may  be  genital  or  extra 
genital  in  its  origin. 

The  former  occurs  from  sexual  contact  with  a  person  in  whom 
the  disease  is  present.  The  latter  originates  from  sources,  e.g., 
kissing  a  syphilitic,  examination  of  syphilitics  by  physicians,  etc., 
also  from  contact  with  some  article  which  has  been  contaminated 
with  the  secretions  of  a  syphilitic  individual.  In  this  form  of 
syphilis  the  site  of  the  initial  lesion  is  extra  genital.  This  type  of 
infection  was  termed  by  Bulkley,  "Syphilitic  Insontium,"  or 
syphilis  of  the  innocents. 

238 


ETIOLOGY.  239 

Hereditary  syphilis  is  derived  from  one  or  both  parents  in  whom 
the  disease  had  been  present  at  the  time  of  conception. 

Immunity. — All  animals  excepting  the  ape  are  immune  to 
syphilis,  this  having  been  proved  by  careful  experiments,  therefore, 
it  is  a  disease  from  which  mankind  alone  suffers.  Metchnikoff 
and  Roux  succeeded  in  inoculating  ten  chimpanzees  with  syphilitic 
virus  from  the  primary  and  secondary  lesions,  and  have  obtained 
positive  results  in  every  case.  A  person  who  has  been  once  in- 
fected with  syphilis  was  formally  considered  immune  to  subsequent 
infection  of  the  disease,  although  this  rule  was  not  without  ex- 
ception. It  is  now  however  an  established  fact,  that  if  a  patient 
is  cared  of  syphilis  he  is  not  immune  but  can  again  acquire  the 
disease. 

Etiology  of  Syphilis. — Until  recently  the  specific  organism 
of  syphilis  had  not  yet  been  isolated,  and  in  fact  the  entire  bacteri- 
ology of  this  disease  was  altogether  unsettled,  as  to  the  exact  causa- 
tive factor.  Various  investigators  had  found  organisms,  claiming 
them  to  be  specific. .  These  were  obtained  in  smears  or  secretions 
of  the  various  lesions  and  infected  tissues,  at  different  stages  of 
the  disease. 

The  most  important  observation  upon  the  causative  factor  of 
syphilis  has  been  made  by  Schaudin  and  Hoffman,  who  have 
found  quite  constantly  in  primary  and  secondary  lesions  of  the 
disease,  a  spirochaeta,  which  owing  to  its  characteristic  refractivity 
to  stains,  they  have  called  the  spirochaeta  pallida.  Some  observers 
who  have  found  the  same  organism  quite  as  constantly  as  the  above, 
propose  the  name  treponema  pallidum.  The  discovery  of  the 
spirochaeta  pallida,  however,  has  probably  been  given  more  credence 
than  any  of  the  hitherto  alleged  specific  organisms  of  syphilis. 
It  has  likewise  been  found  and  confirmed  by  the  best  authorities  the 
world  over. 

The  parasite  is  an  extremely  delicate  wavy  spiral  from  4  to  14  // 
in  length  with  decidedly  pointed  ends  and  having  from  3  to  8 
curves.     In  the  fresh  condition  it  is  seen  to  be  actively  motile. 

Associated  with  the  organism  in  nearly  all  the  lesions  is  another 


240  SYPHILIS. 

larger,  more  darkly  staining  spiral,  called  the  spiroch^ta  refrin- 
GENS,  which  has  been  found  in  other  lesions  than  those  to  syphilis. 
The  probability  that  this  organism  (the  spirochaeta  pallida) 
is  the  caustive  factor  of  the  disease,  is  strengthened  by  the  fact  that 
a  number  of  observers  have  demonstrated  its  presence  in  the  blood 
and  organs  of  congenitally  infected  children. 

For  a  demonstration  of  the  organism,  a  spread  is  made  upon  a 
cover  glass  from  a  chancre,   mucous  patch,   or  from  the  serum 


/  ^H^         ^"Hf 


x 


%=> 


Fig.  66. — The  Spiroch^ta  Refringens  is  the  larger  and  more  darkly  stained 
organism,  while  the  lightly  stained  and  more  delicate  parasite  is  the  Spiroch^ta 
Pallida.  {Treponema  pallidum.)  (From  a  chancre  stained  with  Wright's -blood 
stain.)      (Rosenberger.) 

obtained  from  the  eruption  and  dried.  It  is  then  stained  with 
Wright's  stain,  or  what  is  better,  Giemsa's  azure  blue  solution,  or 
by  Levaditi's  method,  using  silver  nitrate  as  the  stain.  The 
india-ink  method  is  another  excellent  stain. 

With  the  latter,  fixation  of  the  spread  must  be  facilitated  with 
absolute  alcohol  for  15  to  30  minutes,  the  stain  applied  for  from 
30  min.  to  24  hours,  washed  in  water,  dried,  and  examined  with 
a  I  / 12  inch  oil  immersion  lens. 


ETIOLOGY.  .        241 

With  Wright's  stain,  it  can  be  demonstrated  by  applying  the 
dye  in  exactly  the  same  manner  as  for  staining  a  film  of  blood. 

By  either  method  the  organism  is  decidedly  pale  blue,  while  the 
spirochaeta  refringens  is  deep  purple.  In  most  preparations  from 
the  lesions,  but  one  or  two  spirochaeta  pallida  are  found,  while  the 
spirochaeta  refringens  may  be  relatively  numerous. 

In  considering  the  cause  of  syphilis  in  the  present  state  of  our 
knowledge,  it  may  be  best  to  leaven  our  belief  in  this  latest  discovery 
with  a  proper  amount  of  conservatism. 

The  Dark  Ground  Illuminator.^ — A  much  more  convenient  as 
well  as  infinitely  more  reliable  method  of  demonstrating  the  organ- 
ism is  in  the  living  state,  by  means  of  the  so-called  dark  ground 
illuminator.  This  method  was  described  by  the  Rev.  J.  B.  Read, 
in  1837,  who  used  practically  the  same  apparatus  that  we  are  using 
to-day.  Read  described  his  method  just  at  the  time  Prof.  Abbe 
brought  out  his  well-known  substage  condenser  and  in  the  ex- 
citement over  Prof.  Abbe's  invention  the  dark  ground  illuminator 
was  forgotten  until  rediscovered  by  Reichert,  the  microscope 
manufacturer  of  Vienna,  in  1907. 

The  advantage  of  this  method  depends  on  the  illumination,  the 
principle  of  which  is  the  same  as  that  causing  dust  particles  to 
become  visible  when  passing  through  a  beam  of  sunlight. 

The  apparatus  of  Reichert  consists  of  a  metallic  plate,  having 
a  hole  in  the  center,  above  which  is  fitted  a  piece  of  glass  having 
a  circular  excavation  on  its  under  surface;  the  sides  of  this  exca- 
vation are  ground  at  a  certain  angle  and  silvered.  By  means  of  a 
revolving  disc  different  sized  diaphragms  are  used  to  cover  the  cen- 
tral part  of  the  excavated  area,  so  that  when  the  light  is  reflected 
up  from  the  plane  mirror  of  the  microscope,  only  the  marginal  rays 
reach  the  glass  plate.  These  impinge  on,  and  are  reflected  by  the 
silvered  sides  of  the  excavation  to  a  central  point  i  mm.  above  the 
surface  of  the  glass  plate.  Any  solid  body  here  will  intercept 
these  rays  and  appear  as  luminous  objects  on  a  dark  ground.  By 
this  method  it  is  possible  to  see  the  particles  of  colloidal  substances 
in  their  solutions. 

^Harris  &  Corbus,  Journal  of  the  U.  M.  A.,  Dec.  5,  1908. 
16 


242  SYPHILIS. 

The  Reichert  Instrument. — A  form  of  dark  ground  illuminator 
is  now  manufactured  by  most  of  the  microscope  makers,  but  the 
Reichert  instrument  is  superior  to  others  for  the  following  reasons: 

1.  It  can  be  used  on  any  kind  of  microscope. 

2.  By  means  of  the  revolving  diaphragm  the  amount  of  light 
may  be  varied  at  will. 

3.  It  is  possible  to  change  from  the  dark  ground  method  to 
the  ordinary  method  of  transmitted  light  by  merely  revolving 
the  diaphragm. 

The  method  of  using  the  apparatus  is  as  follows: 
The  Abbe  condenser  is  removed.  A  strong  light  is  necessary; 
one  may  use  sun  or  arc  light,  a  Nernst  lamp  or  an  inverted  Welsbach. 
Except  with  the  sun  or  arc  light,  a  six-inch  condenser  lens  is  neces- 
sary, or  a  large  glass  globe  filled  with  water  serves  the  same  purpose. 
The  illuminator  is  placed  on  the  stage  of  the  microscope,  and  by 
means  of  the  low  power  the  circle  which  is  etched  on  the  glass  plate 
is  brought  into  the  center  of  the  field  and  the  apparatus  fixed  in 
this  position  by  means  of  the  clips  on  the  microscope.  A  drop  of 
immersion  oil,  free  from  air-bubbles,  is  placed  on  the  center  and 
the  prepared  slide  put  in  place,  great  care  being  taken  to  avoid  the 
formation  of  air-bubbles.  When  the  preparation  is  examined  with 
the  low  power,  if  the  light  is  placed  right  and  the  apparatus 
centered,  one  observes  a  bright  central  point.  The  high  power  is 
now  turned  on  and  the  field  is  seen  to  be  dark,  with  luminous  points 
and  bodies. 

Preparation  of  the  Specimen. — The  method  of  preparing 
the  specimen  is  very  important.  The  slide  must  be  i  mm.  thick, 
and  both  slide  and  cover  glass  must  be  perfectly  clean  and  well- 
polished,  as  any  turbidity  or  scratches  disperse  the  light  and  cause 
annoying  halos,  which  prevent  the  dark  ground  effect  or  interfere 
with  the  examination.  Air-bubbles  in  the  specimen  also  cause 
these  disturbing  effects.  The  specimen  must  be  as  thin  as  possible. 
The  observation  is  best  made  with  a  dry  system,  using  a  Leitz 
1/8  inch  objective  and  a  No.  5  ocular.  One  can  use  an  oil  im- 
mersion; in   this   case,  however,  it   is   necessary  to  diminish  the 


ETIOLOGY.  243 

aperture  of  the  objective  by  inserting  a  truncated  cone  back  of  the 
front  lens  of  the  objective.  This  cuts  out  the  diverging  rays  of 
Ught,  which  otherwise  would  flood  the  field. 

Method  of  Obtaining  the  Material. — ^For  chances,  mucous 
patches,  and  condylomata  it  is  sufi&cient  to  clean  the  lesions  thor- 
oughly with  warm  water.  They  are  then  irritated  by  being  rubbed 
vigorously  with  a  piece  of  gauze.  This  causes  an  abundant  exu- 
dation of  serum.  A  small  drop  of  this  is  placed  on  a  cover  glass, 
which  is  now  carefully  inverted  on  the  slide  as  in  making  a  fresh 
blood  preparation.  It  is  well  not  to  have  much  admixture  of  blood, 
as  the  blood  cells  interfere  somewhat  with  the  observation.  For 
cutaneous  lesions  one  may  take  a  drop  of  blood  from  the  lesions 
and  often  find  the  organism.  The  best  method,  however,  is  to 
scarify  the  lesion  down  to  the  papillary  layer  and  then  apply  a  small 
cupping  glass.  The  abundant  exudate  of  serum  usually  contains 
numerous  spirochsetes. 

On  looking  at  a  specimen  containing  serum  from  a  chancre  one 
sees  numerous  small,  round  luminous  bodies  which  have  a  very 
active  Brownian  movement.  These  particles  of  albumin  are  prob- 
ably identical  with  the  blood-dust  of  Miiller.  If  the  cleansing  has 
not  been  thorough,  one  often  sees  various  forms  of  bacteria,  the 
cocci  looking  like  pearls.  The  leucocytes  are  seen  as  a  mass  of 
white  granules  surrounding  the  dark  nucleus,  the  various  forms 
being  easily  differentiated.  One  often  sees  the  ameboid  movement 
and  the  granules  in  an  active  Brownian  motion.  The  red  corpuscles 
show  as  a  luminous  ring  surrounding  a  central  pale  reddish  zone. 

Changes  oe  the  Blood  in  Syphilis. — In  all  stages  of  syphilis 
there  is  more  or  less  of  a  reduction  in  the  number  of  red  cells,  and 
a  consequent  diminution  in  the  haemoglobin,  which  may  be  transitory 
or  permanent.  In  some  cases,  however,  there  may  be  no  changes 
at  all  detected. 

Lymphocytosis  in  various  degrees  is  an  almost  constant  con- 
dition. The  effect  of  the  disease  upon  the  blood  usually  depends 
upon  the  severity  and  the  duration  of  the  symptoms. 


244  SYPHILIS. 

ACQUIRED    SYPHILIS. 

Ricord  divided  the  disease  into  three  stages,  the  primary, 
secondary,  and  the  tertiary  periods. 

Primary  syphilis  consists  of  two  periods  op  incubation.  The 
first  constitutes  the  time  which  elapses  between  the  date  of  the 
beginning  of  the  infection,  and  the  appearance  of  the  primary  lesion. 
The  second  is  the  interval  between  the  appearance  of  the  initial 
lesion  and  the  secondary  manifestations.  The  first  period  may 
last  from  lo  to  98  days  with  an  average  of  21  days.  The  second 
period  of  incubation  lasts  usually  about  six  weeks,  but  may  vary 
from  four  to  twelve  weeks  in  its  duration.  These  two  periods  con- 
stitute the  primary  stage.  In  other  words,  from  the  date  of  the 
infecting  coitus  to  the  appearance  of  the  secondary  manifestations 
constitutes  the  first  or  primary  stage  of  syphilis. 

The  interesting  morbid  phenomena  observed  during  this  stage 
are  the  evolution  of  the  initial  lesion  and  enlargement  of  the 
lymphatics  in  anatomical  relation  to  it.  These  may  be  distinctly 
palpated,  usually  in  from  the  seventh  to  the  tenth  day  after  the 
appearance  of  the  chancre.  At  the  end  of  the  second  period  of 
incubation  with  the  appearance  of  the  secondary  manifestations, 
the  disease  may  be  said  to  be  fully  developed,  and  from  that  time  on 
the  secondary  stage  begins. 

Tertiary  syphilis  is  the  third  or  last  period  of  the  disease  and 
comprises  the  destructive  syphilitic  processes  of  these  structures 
as  well  as  the  deep  tissues  of  the  viscera. 

Prognosis. — The  virulence  of  syphilitic  processes  is  always 
most  doubtful  and  depends  largely  on  the  resisting  power  and 
habits  of  the  individual.  It  is  accordingly  upon  this  that  the 
prognosis  must  be  based. 

The  conditions  which  may  considerably  complicate  the  treat- 
ment of  syphilis,  when  they  co-exist,  are  tuberculosis,  alcoholism, 
old  age,  cancer,  jaundice,  malaise,  diabetes,  albuminuria,  nephritis, 
gout  and  rheumatism,  and  any  of  the  acute  infectious  disease,  e.g., 
typhoid  fever,  diphtheria,  anaemia,  and  small-pox.     Taylor  says 


VEHICLES    OF    INFECTION. 


245 


clinical  observation  has  shown  that  neither  extragenital  chancre  nor 
ulceration,  phagedena  and  gangrene  of  the  chancre,  are  neces- 
sarily ominous.  Diminution  in  severity  of  the  disease  over 
that  of  a  few  years  ago  is  due  to  improved  treatment  and  increased 
immunity  through  heredity.  In  the  healthy,  the  disease  is  elimi- 
nated if  active  treatment  is  instituted  promptly  and  continued  for 
two  or  three  years.  Women  are  less  frequently  attacked  by  cere- 
brospinal affections  than  men.  Severity  and  malignancy  among 
the  lower  orders  are  due  to  carelessness.  The  causes  of  tertiary 
syphilis  are  insufficient  treatment  in  the  secondary  stage,  lowered 
nutrition,  and  diseased  conditions.  Syphilitic  tissues  are  hotbeds 
for  the  tubercle  bacillus.  Chronic  alcoholism  induces  severe  lesions 
and  causes  the  disease  to  run  into  the  tertiary  stage.  Bright*s  dis- 
ease, diabetes,  scurvy,  and  other  circulatory  diseases  are  grave 
complications.  The  depression  and  debility  following  infective 
diseases  render  the  course  severe. 

Vehicles  of  Infection. — The  sources  of  infection  other  than  the 
genitalia  may  be  any  vehicle  which  has  been  contaminated  by  a 
syphiHtic  person.  Most  commonly  the  disease  is  derived  from  the 
secretions  of  the  initial  lesion,  condylomata,  and  the  mucous  patches, 
etc.,  when  they  are  either  genital  or  extragenital.  The  virulency  of 
the  secretions  of  pustules,  papules,  and  tubercules  are  also  prolific 
sources  of  contagion.  The  virus  brought  into  contact  with  a  non- 
syphilitic  person  may  give  rise  to  an  initial  lesion,  at  a  point  of 
abrasion  or  other  solution  of  continuity  anywhere  about  the  body. 

While  the  secretions  of  the  secondary  lesions  are  highly  infectious, 
the  same  is  not  true  of  the  tertiary.  The  semen  of  a  man  in  the 
secondary  stage  is  not  infectious  on  the  mucous  membrane  of  the 
woman,  but  should  conception  take  place  the  disease  is  most  Hkely 
to  be  transmitted. 

Cigars,  tooth-powders,  tooth-brushes,  pipes,  cigarette  and  cigar 
holders,  drinking  and  eating  utensils,  razors,  towels,  sponges,  linen, 
masks,  wash  rags,,  pins,  needles,  children's  toys,  surgical  and  mani- 
cure instruments,  syringes,  paper  cutters,  lead  pencils,  telephone 
mouth  pieces,  musical  instruments,  and  vaccination  are  some  of  the 
mediums  of  conveying  syphilitic  virus. 


246  SYPHILIS. 

Modes  of  Infection. — Direct  and  indirect  or  mediate  contact  and 
by  inheritance.  Most  commonly,  however,  the  disease  is  acquired 
by  direct  contact.  The  sexual  act  is  the  most  frequent  mode  of  its 
communication,  but  it  may  be  also  transmitted  by  acts  of  sexual 
perversion.  In  these  instances  the  chancre  is  usually  extragenital. 
The  lesions  and  secretions  which  are  contagious  have  already  been 
enumerated,  but  the  means  of  their  conveyance  may  be  summarized 
as  follows:  kissing;  nursing  babies;  bites  from  infected  persons; 
surgeons;  nurses;  and  mid- wives;  incidental  to  examination  or 
treatment,  or  in  operating  upon  syphilitic  persons,  skin  grafting, 
and  tattooing.  (Taylor.)  Dentists  may  contract  syphilis  from 
lesions  of  the  mouth  of  infected  patients,  or  may  convey  the  disease 
to  many  persons  by  means  of  instruments  smeared  with  syphilitic 
secretion. 

Cultivation  of  the  Spirochaeta  pallida  in  pure  cultures  and 
with  little  loss  of  virulency  is  the  latest  achievement  in  the  way  of 
new  and  more  efficient  diagnostic  aids — Noguchi  and  Hoffman 
both  working  independently  announced  their  results  about  the  same 
time.  Noguchi' s  method  consists  in  the  inoculation  of  infected 
tissue  from  a  rabbit  into  a  diluted  serum  to  which  a  piece  of  sterile 
fresh  animal  tissue  had  been  added.  This  is  then  incubated  under 
strictly  anaerobic  conditions.  Injection  of  the  cultures  into  rabbits 
is  followed  after  a  suitable  period  by  local  lesions,  in  which  are 
found  both  the  anatomic  changes  characteristic  of  syphilis  and 
typical  spirochetes  in  large  numbers.  The  specificity  of  the  Spiro- 
chaeta pallida  as  the  cause  of  syphilis  is  thus  more  firmly  established 
than  ever. 


CHAPTER  XV. 

PRIMARY   SYPHILIS. 

Primary  syphilis,  or  the  first  stage,  consists  principally  of  the 
initial  lesion,  or  chancre,  and  an  associated  lymphatic  enlargement. 

CHANCRE. 

Synonyms. — Syphilitic  chancre,  primary  lesion,  initial  lesion, 
primary  sclerosis,  hard  chancre,  infecting  chancre. 

The  initial  lesion  is  the  best  of  these  various  synonyms  and  the 
most  appropriate,  as  the  term  implies  it  to  be  the  first  manifestation 
of  the  infection  and  is  due  to  the  action  of  the  treponema  pallidum. 

The  first  period  of  incubation  ends  with  the  appearance  of  the 
initial  lesion. 

Site. — May  be  genital  or  extragenital.  May  occur  on  any  part 
of  the  body,  distinguishing  it  therefore,  particularly,  from  the  chan- 
croid. It  is  very  frequently  found  at  the  corona  sulcus,  the  margin 
of  the  prepuce,  the  frenum,  meatus  urinarius,  glans  penis,  the  tegu- 
ment or  shaft  of  the  penis,  scrotum,  the  perineum,  and  anus.  In 
women,  genital  chancres  appear  most  frequently  in  the  following 
order:  the  labia  majora  and  minora,  fourchette,  the  cervix,  clitoris, 
and  meatus  urinarius.  Chancres  of  the  vagina  are  very  rare  but 
when  they  do  occur  they  usually  escape  diagnosis,  on  account  of  it 
being  a  comparatively  painless  lesion.  A  very  important  feature  of 
the  genital  chancre  in  women  is  that  the  inguinal  glands  are  as  a 
rule  not  involved. 

The  extragenital  chancres  are  most  frequently  seen  on  the  lips, 
fingers,  nipples,  anus,  tonsils,  tongue,  nares,  alae  of  the  nose,  thighs, 
arms,  and  toes.  Initial  lesions  are  usually  solitary  but  may  be 
found  multiple,  though  rarely. 

247 


248  PRIMARY    SYPHILIS. 

Other  conditions  which  must  not  be  lost  sight  of  in  establishing 
an  accurate  diagnosis  of  a  genital  chancre  are  chancroids,  abra- 
sions, herpes  progenitalis,  and  scabies. 

Apart  from  the  genitalia,  the  lips  are  the  most  frequent  seat  of 
the  extragenital  chancre.  As  chancroids  are  rarely  if  ever  extra- 
genital, the  most  common  disease  with  which  chancre  may  be 
confounded  is  epithelioma  on  the  lip,  a  differential  diagnosis  of 
which  is  as  follows: 

Initial  Lesion.  j  Epithelioma. 

Rapid  in  its  onset.  Gradual  in  its  development. 

Duration  limited.  I       No  duration. 

Induration  marked  and  well  defined.  Induration  diffused. 

Submaxillary     adenitis,     but     not  Submaxillary  glands  inflamed, 

painful. 

Involvement  of  the  glands  is  rapid.  Involvement  of  glands  delayed. 

Initial  lesion  may  occur  in  any  age  I  Only  occurs  after  middle  life  or  in 
or  sex.  old  age,  most  often  in  male  sex,  pipe 

smokers  especially. 

Is  more  or  less  painful.  Epithelioma  not  painful. 

Swelling  very  marked.  |        Swelling  not  so  marked. 

Microscopic   examination  negative.  Micros  opic  examination  of  a  sec- 

tion will  reveal  its  nature. 

Spirocheta  pallida  present.  Absent. 

The  period  of  incubation  of  the  chancre  varies  from  10  to  98 
days,  with  an  average  of  21  days. 

Induration  of  Chancres. — This  is  one  of  its  constant  distin- 
guishing features  and  is  easily  recognized  by  the  sense  of  touch. 
The  sclerosis  or  character  of  its  induration  may  be  annular,  nodular, 
parchment,  or  laminated. 

Duration. — Always  indefined,  as  it  varies  considerably.  The 
lesion  may  last  anywhere  from  a  few  days  to  several  weeks — and 
sometimes  persist  even  for  several  months.  The  lesion  usually 
disappears,  however,  with  the  onset  of  the  secondary  manifestations. 
Should  they  last  beyond  this,  the  specific  constitutional  treatment 
will  usually  hasten  their  resolution. 


VARIETIES    OF    INITIAL    LESION.  249 

Diagnosis. — The  principal  diagnostic  features  of  the  chancre 
are  (a)  its  period  of  incubation,  (b)  the  character  of  its  induration, 
(c)  and  the  accompanying  enlargement  of  the  adjacent  lymphatics, 
and  the  finding  of  the  spirochete  palleda. 

VARIETIES  OF  INITIAL  LESION. 


Superficial  erosion. 

Superficial  ulceration. 

Papular. 

Deep  ulcerative  or  Hunterian. 

Silver  spot  (Taylor). 


Umbilicated  or  follicular. 

Multiple  herpetiform  (Dubuc). 
Infected     balano-posthitis      (Mau- 
riac) . 

Mixed  infection. 


The  superficial  erosion  is  the  commonest  variety  of  the  initial 
lesions  but  yet  very  often  overlooked.  It  is  superficial,  roundish 
or  oval  in  shape,  and  has  a  smooth  surface  resting  on  a  parchment 
bed  of  induration.  It  may  be  dry  or  slightly  moist  with  a  thin 
serous  secretion. 

The  superficial  ulcerative  variety  have  an  irregular  outline 
with  sloping  edges,  slightly  elevated,  sometimes  resembling  a  fissure. 
This  also  rests  upon  a  thin  layer  of  induration. 

The  papular  chancre  is  non-ulcerating,  indurated  at  its  base, 
dry,  and  scaling,  and  usually  occurs  on  skin  surfaces  at  the  point 
of  the  inoculation. 

Deep  ulcerative  or  Hunterian  chancre  rests  on  a  large  area  of 
induration.  It  is  craterform,  or  scooped  out  in  its  appearance,  very 
irregular  in  its  shape,  its  floor  representing  a  deep  fissure.  The  edges 
are  sloping,  and  markedly  indurated.  This  type  varies  in  size,  but 
may  be  said  to  be  as  large  on  an  average  as  a  hazel-nut.  This 
variety  of  chancre  usually  occurs  as  a  result  of  the  action  of  caustics, 
friction,  improper  treatment,  and  filth. 

Silver  spot  is  one  of  the  more  rare  variety,  and  was  first  described 
by  Taylor,  as  resembling  a  pin-head  sized  spot  of  mucous  membrane, 
which  had  been  touched  with  carbolic  acid  or  nitrite  of  silver.  It 
generally  occurs  on  the  glans  penis  and  on  the  lips  of  the  meatus. 

The  follicular  or  umbilicated  chancre  is  another  rare  variety 


250  PRIMARY   SYPHILIS. 

in  which  are  found  small  and  sometimes  large  cup-shaped  lesions 
of  a  light  reddish  hue.     (Hyde  and  Montgomery.) 

Multiple  herpetif  orm  chancres  occur  in  crops,  first  as  a  minute 
superficial  erosion,  persistent  in  its  course,  then  multiple  in  num- 
ber, and  having  a  hemorrhagic  tendency. 

Infective  balano-posthitis  is  the  development  of  the  primary 
lesion  involving  the  mucous  layer  of  the  prepuce,  and  sometimes 
of  the  glans,  and  is  really  a  specific  erosion.  The  prepuce  is  thick- 
ened, reddened,  and  inflamed. 

Mixed  infection  or  mixed  chancre  is  a  condition  in  which  the 
initial  lesion,  as  the  consequence  of  pyogenic  infection,  undergoes 
ulceration,  resulting  in  one  or  more  lesions,  strongly  resembling 
the  chancroid  with  the  characteristic  induration  of  the  primary 
lesion.  It  is  really  a  condition  in  which  there  is  a  simultaneous 
presence  of  the  chancre  and  the  chancroid. 

Chancre  of  the  urethra  which  may  occur  at  the  meatus  or  fossa 
navicularis  are  extremely  important  and  difficult  of  early  diagnosis. 
When  the  meatus  is  involved,  the  induration  is  very  marked,  im- 
parting to  the  touch  a  sensation  of  a  pea  in  the  urethra.  An  im- 
portant diagnostic  symptom  of  chancre  in  the  meatus  is  the  dis- 
coloration of  the  glans,  which  may  become  purplish-blue  in  color" 
Lesions  at  this  point  are  also  always  attended  with  great  pain  and 
burning  on  urination.  When  the  urethral  chancre  is  in  the  fossa 
navicularis,  the  first  symptom  is  a  muco-purulent  discharge  with 
glueing  of  the  lips  of  the  meatus,  resembling  gonorrhoea.  There 
is  little  or  no  pain  except  on  urination,  and  with  an  erection.  By 
means  of  the  endoscope,  palpation  of  the  adjacent  lymphatic  glands 
and  the  nodular  induration  at  the  point  of  the  lesion,  the  diagnosis 
is  readily  made. 

Chancres  of  the  finger  occur  frequently  among  physicians,  den- 
tists, accoucheurs,  and  nurses  of  both  sexes.  It  is  most  commonly 
found  in  the  form  of  an  excoriative  or  ex-ulcerative  area,  and  is 
seen  usually  near  or  at  the  tip  of  the  finger.  In  its  incipiency  it 
is  indolent  and  painless,  but  in  the  course  of  a  few  weeks  develops 
into  a  large,  smooth  or  granular  mass  of  morbid  tissue.     These 


COMPLICATIONS.  251 

conditions  are  attended  with  no  characteristic  induration.  Digital 
chancre  must  not  be  mistaken  for  simple  sores  or  whitlows.  Their 
specific  nature  is  readily  confirmed  by  an  examination  of  the  epi- 
trochlear  and  axillary  glandular  enlargement,  even  before  the  erup- 
tion appears. 

Chancre  of  the  tongue  appears  as  a  well-defined  mass,  or  nodule 
at  the  tip  or  lateral  border.  The  surface  is  eroded,  and  covered 
with  a  pseudomembrane.  They  are  usually  indolent  and  persist- 
ent in  their  course.  The  submaxillary  glandular  enlargement  is  a 
great  aid  in  the  diagnosis.  It  is  important  to  bear  in  mind  the 
differential  features  of  chancre  from  that  of  cancer  of  the  tongue. 
(See  differential  table.)  Both  begin  as  a  small  nodule  and  are  at- 
tended with  glandular  enlargements.  The  age  is  an  important  fac- 
tor in  making  the  diagnosis.  In  persons  under  forty-five  years,  the 
lesion  will  usually  be  specific.  When  past  middle  life  or  in  late 
years  the  probabilities  are  that  the  lesion  is  cancerous.  Chancres 
of  the  gums  and  hard  palate  are  very  rare  and  difficult  to  diagnose 
owing  to  the  uncertainty  of  the  condition  being  simply  a  mucous 
patch. 

Chancres  of  the  tonsils  occur  frequently  and  generally  result 
from  perversion  of  the  sexual  act.  Therefore,  when  a  patient  com- 
plains of  a  chronic  sore  throat  a  physician  should  always  be  on  the 
look-out  for  the  accompanying  submaxillary  and  sublingual  glan- 
dular enlargement  which  soon  becomes  marked. 

Termination. — Chancres  rarely  result  in  any  destruction  of  the 
tissue  but  usually  terminate  by  resolution,  leaving  but  a  faint  trace 
or  pigment.  The  secretion  of  the  initial  lesion  is  serous,  or  sero- 
purulent  in  character.  The  latter  secretion  is  due  to  extraneous 
causes,  e.g.,  by  pyogenic  organisms,  etc.  When  this  occurs  it  often 
leaves  a  more  or  less  well  developed  scar. 

Complications. — For  various  reasons,  the  initial  lesion  may  un- 
dergo certain  changes,  most  common  of  which  are  septic  inflam- 
mation, chancroids,  papillomata,  phagedena,  gangrene,  and  mucous 
patches,  each  of  which  may  be  considered  as  a  complication. 


252  PRIMARY    SYPHILIS. 

TREATMENT  OF  CHANCRE. 

It  has  been  conclusively  proven  that  it  is  futile  to  attempt  to 
abort  syphilis  by  instituting  immediate  constitutional  specific  treat- 
ment. Such  radical  measures  as  early  cauterization  or  extirpation 
of  the  glands  in  anatomical  relation  to  the  sore,  and  excision  of  the 
chancre  have  invariably  failed.  The  failure  to  abort  is  on  account 
of  the  fact  that  there  is,  by  the  time  the  initial  lesion  appears,  a 
complete  systemic  involvement,  even  though  the  syphilitic  proc- 
esses have  not  had  sufficient  time  to  become  manifest.  There- 
fore, the  treatment  of  the  chancre  simply  resolves  itself  into  hygi- 
enic, tonic,  and  local  measures.  In  its  incipiency  the  chancre  often 
resembles  an  innocent  erosion  or  abrasion  appearing  as  a  minute, 
smooth,  round  or  oval  excoriation,  or  as  a  simple  papule. 

It  is  of  paramount  importance,  at  this  time  especially,  that  the 
patient  isolate  or  reserve  himself,  so  far  as  practical,  until  the  nature 
of  the  lesion,  by  its  later  evolution,  is  definitely  known  and  thus 
avoid  the  danger  of  infecting  other  persons. 

The  use  of  acids  and  caustics  is  to  be  condemned,  as  they  are 
absolutely  of  no  avail,  and  only  tend  to  increase  the  sclerosis  which 
may  remain  permanent.  The  lesion  must  be  kept  constantly  clean, 
the  patient  instructed  to  immerse  and  bathe  the  parts  in  mild  anti- 
septic solutions  several  times  a  day.  Hot  normal  saline  solution 
and  boric  acid  (saturated  solution),  potassium  permanganate  1-3000 
are  all  excellent  antiseptic  solutions.  The  part  is  then  carefully 
dried,  a  thin  layer  of  absorbent  cotton  is  spread  over  the  surface 
of  the  lesion  and  saturated  with  lotio  nigre,  which  consists  of: 

I^      Calomel grs.  xxiv. 

Aquae  calcis §   vj. 

The  patient  should  be  instructed  to  keep  this  cotton  moist  con- 
tinuously, and  when  it  is  changed  always  bathe  the  part  previously 
so  that  this  cotton  covering  will  separate  from  the  granulating  area 
without  bleeding  or  pain.  The  lotion  applied  in  this  manner  not 
only  acts  as  a  protective  covering  to  prevent  irritation  but  is  also 


TREATMENT    OF    CHANCRE.  25 


O 


slightly  stimulating.  Copper  sulphate  solution  r-200  and  yellow 
wash  may  be  also  used  in  the  same  manner,  and  for  the  same  purpose. 
Where  the  chancres  are  covered  with  a  pseudomembrane,  and  there 
is  a  tendency  to  become  necrotic  and  indolent,  it  should  be  sprayed 
with  peroxide  of  hydrogen,  then  immersed  in  any  of  the  above 
antiseptic  solutions,  cocainized,  and  by  means  of  a  small  piece  of 
cotton  wrapped  around  the  end  of  a  tooth-pick,  an  application  of 
acid  nitrate  mercury  i-ioor  nitric  acid  25  to  50  per  cent,  or  pure 
carboHc  acid  should  be  made.  Every  effort  should  be  directed 
toward  preventing  further  ulcerations  and  complications,  thus  by 
destroying  the  pseudomembrane  a  healthy  surface  is  formed. 
Taylor  recommends  the  use  of  mercurial  ointment  applied  on  a  thin 
layer  of  cotton  over  the  sore.  Various  dusting  powders  are  also  of 
use  where  the  lesion  is  granulating.  Iodoform  is  a  most  excellent 
remedy  where  the  patient  does  not  object  to  its  odor.  Calomel  and 
bismuth,  aristol,  iodomuth,  thymiodide,  biodal,  europhen,  and  acet- 
anilid  are  a  few  of  the  many  stimulating  powders  that  may  be  of 
service. 

Lydston  recommends  the  following  formula  as  a  local  application. 
The  odor  of  the  iodoform  being  well  disguised: 

^     Menthol '. gr.  v. 

Iodoform 5  iv. 

Spermaced §   ij. 

Cerate  q.  s.  ad §  iv. 

Chancres  in  women  are  treated  according  to  the  same  principles. 
The  vagina  should  be  irrigated  two  or  three  times  daily  with  warm 
solutions  of  either  boracic  acid,  potassium  permanganate,  zinc 
sulphate,  or  alum.  The  lesions  are  then  thoroughly  dried  and  kept 
free  from  the  vaginal  secretions  by  means  of  a  tampon  of  cotton, 
and  on  it  may  be  applied  a  thin  layer  of  mercurial  ointment.  Appli- 
cations of  sulphate  of  copper  2  per  cent,  are  often  very  effective  in 
stimulating  granulations. 

Where  there  is  any  tendency  to  deep  ulceration,  pure  carbolic  acid 
or  acid  nitrate  of  mercury  i-io  are  efficient  as  an  application.     The 


254  PRIMARY   SYPHILIS. 

use  of  mercurialized  benzo'n  as  an  antiseptic  lotion  is  recommended 
as  effective  in  keeping  the  lesions  clean.     (Hyde  and  Montgomery.) 

Where  the  urethral  orifice  is  the  seat  of  the  chancre,  the  burning 
on  urination  which  almost  invariably  occurs,  may  be  allayed  by 
immersion  of  the  penis  in  warm,  mild  antiseptic  solutions.  The 
lesions  should  then  be  touched  with  silver  nitrate  or  copper  sulphate 
(2  per  cent,  solutions)  and  some  cotton  interposed  between  the  lips 
of  the  urethral  orifice,  so  as  to  keep  the  mucous  surfaces  apart. 
Mercurial  ointment  is  also  of  service  in  these  cases. 

Where  there  is  a  mixed  infection — that  is,  the  simultaneous  pres- 
ence of  the  chancre  and  chancroid,  or  pyogenic  infection  of  the 
initial  lesion — the  treatment  is  practially  the  same. 

Constitutional  specific  treatment,  which  ordinarily  is  never 
begun  until  the  appearance  of  the  secondary  manifestations,  is 
justified  in  some  cases,  simultaneous  with  the  appea  ance  of  the 
primary  lesion.  These  exceptional  instances  are,  where  the  seat  of 
the  lesion  is  on  the  lips,  tongue,  or  conspicuous  anywhere  about  the 
face.  Also  where  a  diagnosis  of  the  specific  nature  of  the  lesion  is 
fairly  well  established.  Urgent  specific  treatment  is  indicated  when 
the  seat  of  the  affection  is  the  soft  palate,  tonsils,  or  pharynx,  and 
particularly  where  there  is  a  threatened  destruction  of  the  part. 

Excision  of  the  chancre  as  early  as  possible  has  many  advocates 
who  claim  it  lessens  the  virulency  of  the  infection  and  in  some 
cases  arrests  all  further  manifestations  of  the  disease.  This  is  not 
to  be  relied  on,  however,  and  should  simply  be  resorted  to  as  an 
accessory  to  the  other  methods  of  constitutional  treatment. 

SECONDARY  SYPHILIS. 

At  the  end  of  the  second  period  of  incubation  with  the  onset  of 
the  cutaneous  manifestations  the  second  stage  of  syphilis  begins. 
Concurrent  with  this,  there  is  likely  to  develop  various  constitutional 
morbid  phenomena.  This  depends  upon  various  factors,  such  as 
the  diatheses,  habits,  poverty,  environment,  and  filth.  Syphilitic 
fever  may  or  may  not  be  present.     The  elevation  of  temperature  has 


SECONDARY    SYPHILIS.  255 

no  distinct  characteristic  feature  from  other  febrile  disturbances. 
It  may  be  said  to  be  of  the  remittent  type  and  sometimes  occurs 
either  early  or  late  in  the  disease.  Neuralgia,  headaches,  and  rheu- 
matoid pains  are  all  attended  with  nocturnal  exacerbations,  which 
is  characteristic  of  its  specific  origin. 

Syphilitic  cachexia  may  develop  at  any  time  during  the  evolution 
of  the  disease.  Generally  occurs  in  the  debilitated  and  where  there 
has  been  improper  hygienic  and  insufficient  specific  treatment. 
Jaundice  is  another  complication  which  may  be  seen  in  the  early 
stage  of  syphilis. 

The  kidneys  and  spleen  may  undergo  some  changes.  The 
former  may  become  the  seat  of  a  mild  or  severe  involvement,  in  the 
early  and  late  stages  respectively.  In  such  instances,  albuminuria 
may  be  found. 

When  the  spleen  is  affected  it  becomes  markedly  enlarged. 

The  osteoscopic  pains  are  also  a  feature  of  early  syphilis,  and  in- 
volve especially  the  sternum,  clavicle,  parietal,  frontal  bones,  and 
the  tibia.  Other  conditions  which  sometimes,  supervene  in  the 
early  secondary  stage  of  syphilis  are  hysteria,  analgesia,  disturbances 
in  the  reflexes,  synovitis,  rheumatism,  tonsillitis,  laryngitis,  pleurisy, 
angina  pectoris,  and  hemorrhagic  effusions.     (Taylor.) 

Adenopathy,  Lymphangitis,  and' Adenitis  or  Bubo. — Co-in- 
cident with  the  development  of  the  initial  lesion  of  syphilis  is  the 
syphilitic  hyperplasia  of  the  lymphatic  glands,  in  anatomical  relation 
to  the  seat  of  the  infection.  From  this  lesion,  the  infection 
promptly  ascends  through  the  perivascular  lymph  spaces  and  en- 
largement of  the  lymphatics  ensues.  This  involvement  is  char- 
acterized by  its  induration,  absence  of  inflammation,  and  its  per- 
sistency. (Taylor.)  The  indurated  vessel  attaining  a  cord-like 
consistency.  The  lymphatics  then  become  indurated,  and  persist 
until  resolution  of  the  chancre  begins.  These  changes  become 
manifest  to  the  touch  between  the  6th  and  loth  day,  after  the 
appearance  of  the  chancre.  The  glands  particularly  involved 
are  usually  in  proximity  to  the  focus  of  the  infection.  When 
the  glands  are  chiefly  implicated,  syphilitic  bubo  results.     They 


256  SECONDARY    SYPHILIS. 

vary  in  size  and  the  glands  readily  distinguishable  from  one 
another  and  are  freely  movable  under  the  skin.  These  are  at- 
tended with  a  little  pain  or  inflammation.  Suppuration  of  the 
syphilitic  bubo  very  rarely  occurs  except  from  a  mixed  infection. 

The  submaxillary  glands  are  distinctly  enlarged,  when  the  nfpples 
and  breast  are  the  seat  of  the  infection.  The  posterior  cervical 
glands  and  the  inguinal  glands  are  also  very  frequently  indurated, 
according  to  the  relation  of  the  seat  of  the  lesion.  The  induration 
usually  reaches  its  full  development  in  the  course  of  10  to  15  days. 
When  glandular  enlargement  is  detected  simultaneous  with  the 
primary  sclerosis,  the  diagnosis  of  specific  infection  can  be  readily 
made. 

Syphilis  of  the  Skin. — Secondary  eruptions,  syphilides,  or 
syphilodermata  include  the  superficial  lesions  of  early  eruptive 
manifestations  of  the  secondary  stage.  They  appear  usually  about 
six  to  seven  weeks  after  the  primary  lesion  of  chancre.  During 
this  interval,  or  second  period  of  incubation,  the  patient  presents 
some  subjective  symptoms.  These  complex  phenomena  or  pro- 
dromes present  certain  characteristics,  which,  together  with  a 
carefully  elicited  history  and  examination  of  the  sore,  usually  furnish 
sufficient  data  to  establish  an  accurate  diagnosis.  The  eruption, 
which  is  general  and  symmetrically  distributed,  presents  peculiar 
distinguishing  feaures  characterizing  it  from  other  skin  diseases 
and  exanthemata.  The  later  lesions  of  the  secondary  stage  have  a 
tendency  to  remain  localized  and  invade  the  deeper  portions  of  the 
skin,  while  tertiary  lesions  are  distinctly  more  persistent  and  chronic 
in  their  course  and  involve  extensively  and  deeply  certain  tissues 
for  which  they  seem  to  have  a  predilection.  Tertiary  lesions  are  as 
a  rule  not  symmetrical.  The  early  eruptions  of  the  secondary 
stage  yield  readily  to  proper  treatment,  and  are  marked  by  the  ab- 
sence of  inflammatory  symptoms  and  to  the  fact  that  they  are  super- 
ficially situated,  being  limited  to  the  skin  and  mucous  membranes 
in  the  form  of  a  generalized  rash.  The  difficulties  in  the  diagnosis 
of  syphilis  have  been  admitted  by  the  most  skillful  diagnosticians. 
The  reason  for  this  is  that  the  cutaneous  manifestations  of  syphilis 


SYPHILIS    OF   THE   SKIN.  257 

may  be  imitated  by  quite  a  number  of  other  less  obnoxious  skin 
diseases  and  that  syphilis  may  often  appear  in  forms  which  simulate 
the  lesions  of  other  dermatoses. 

The  distinguishing  features  which  may  be  regarded  as 
peculiar  to  the  syphilitic  eruption,  are  (a)  its  polymorphism,  i.e., 
several  varieties  of  the  eruption  appearing  at  the  same  time,  (b) 
the  absence  of  the  itching  and  pain,  (c)  its  characteristic  ham  or 
copper  {sepia)  color  pigment,  (d)  the  tendency  to  appear  in  groups 
either  of  circular  or  oval  form,  i.e.,  of  one  variety  of  syphilide,  sur- 
rounded by  those  of  a  different  type,  and  (e)  the  tendency  to  localize  in 
certain  parts,  (f)  the  chronological  sequence  and  course  of  the 
syphilides,  (g)  if  the  blood  be  pressed  out  of  one  of  these  papules 
by  a  piece  of  glass,  othere  will  be  noted  a  brownish-yellow  area,  and 
(h)  their  symmetrical  distribution — where  they  are  found  on  one 
arm — they  will  be  seen  in  a  corresponding  area  of  the  opposite 
arm,  'etc. 

The  color  is  not  due  simply  to  local  hyperaemia  since  it  does 
not  disappear  on  pressure,  but  is  supposed  to  be  due  to  extravasa- 
tion of  red  blood  corpuscles.  Red  is  the  predominant  color  in 
recent  syphilitic  eruptions. 

Another  peculiarity  of  the  syphilides  is  their  localization.  The 
most  common  parts  where  they  appear  are  on  the  scalp  or  at  its 
border,  angles  of  the  mouth,  forehead,  on  the  alae  of  the  nose,  about 
the  anus,  upon  the  genitals,  and  upon  the  palms  (palmar  syphilides) 
(Fig.  67)  and  soles  (plantar  syphilides),  the  flexor  surfaces  of  the 
limbs.  Therefore,  it  is  well  nigh  imperative  that  all  these  parts 
be  examined  as  a  matter  of  routine  in  making  a  diagnosis. 

The  ensemble  of  all  syphilitic  symptoms,  in  exceptional  cases, 
may  be  closely  imitated  by  non  specific  dermatoses.  The 
diagnosis  of  syphilis  can  be  made  with  absolute  certainty  only  when 
based  on  positive  as  well  as  on  negative  findings,  that  is  when  we  not 
only  find  the  characteristic  elements  of  syphilis,  but  when  we  can 
with  certainty  exclude  all  other  skin  diseases  which  may  appear 
under  the  similar  symptoms. 

Some  of  the  drugs  which  may  cause  eruptions  of  the  skin  re- 
17 


258 


SECONDARY    SYPHILIS. 


sembiing  syphilides  are,  belladonna,  copaiba,  quinij.e,  cJdoral,  anti- 
pyrin,  sandal-wood  oil,  iodide  of  potassium,  bromides,  and  chlorate 
of  potassium. 

It   must   also   be   differentiated   from    scabies,    psoriasis,   lupus 


Fig.  67. — Papulo-squamous  syphiloderm  of  the  palm.     (After  Schamberg.) 

vulgaris,  tinea  versicolor,  measles,  smallpox  chickenpox,  and 
varioloid,  the  eruptions  of  which  strongly  resemble  syphilides. 
The  concomitant  and  corroborative  signs  and  symptoms  of 
secondary  syphilis  may  be  enumerated  as  follows:  (i)  the 
lymphatic  glandular  involvement,  (2)  the  primary  chancre,  (3)  the 


PERIODS    OF    SYPHILIDES. 


259 


secondary  syphilides,  (4)  lesions  of  the  tongue  and  buccal  mucous 
membrane,  (5)  continued  hoarseness  as  the  symptom  of  tonsillar 
chancre,  (6)  the  loss  of  hair,  (7)  headache,  (8)  osteoscOpic  pains 
with  nocturnal  exacerbations,  (9)  fever,  and  (10)  albuminuria. 
In  the  SECOND  period,  the  blood  is  affected  by  a  diminution  of 
the  haemoglobin  and  red  corpuscles,  giving  rise  to  syphilitic  anaemia, 
which  is  persistent,  especially  in  the  ill-nourished. 

SKIN  ERUPTIONS  IN  SYPHILIS. 

I.  Erythema:     a.  Roseolar. 

b.  Macular. 

c.  Purpuric. 
Dry         f  f  Large  and  small  flat  lenticular. 

Large  and  small  conical  or  miliary 
Condylomata 


Papular 


Secondary 


Moist 


Large  and  small 


Mucous  patches 


3.  Pustular: 


Acneform 

Variolaform 

Impetigoform 

Ecthymafonn 

/  Large  and  flat  rupea 
4.  Pigmentary:     i    ^  n  ^       ■         ^-     s- 

°  -^       (^  Large  flat  or  impetigoform 

I  Ulcerative 


Tertiary        < 


5.  Tubercula': 

6.  Bullous. 

7.  Rupial 

8.  Gummatous 

9.  Serpiginous 


1    Non-ulcerative 


PERIODS  OF  SYPHILIDES.     (Sturgis  and  Cabot.) 
Variety.  Time  Due.  Duration. 


Erythema 
Papular 
Pustular 
Gummata 


6  to  12  weeks 
2  to  6  months 
6  to  15  months 
I  to  5  years  or  more 


3  to  6  weeks 

4  to  8  weeks 

2  to  4  months  or  more 
1/2  to  2  years  or  more 


Syphilides  appearing  in  combination  such  as  papule  and  pustules 
are  often  referred  to  as  "papulo-pustular,"  "pustulo-crustaceous," 
"syphilo-derma,"  ''papulo-squamous,"  etc.     (Fig.  67.) 


26o  SECONDARY   SYPHILIS. 

The  erythematous  syphilides  are  usually  the  first  of  the  syphi- 
litic eruptions  to  make  their  appearance. 

Synonyms. — Syphilitic  roseola,  macular  syphilides,  exanthema- 
tous  syphilides.  The  erythematous  S5^hilide  is  of  a  very  faint 
pinkish  color,  consisting  of  round  or  oval  areas  with  a  distinct  or 
irregular  outline,  averaging  about  i  c.c.  in  diameter.  Sometimes 
they  appear  as  a  decided  red  or  even  purplish  hue. 

Exposure  to  cold  accentuates  their  color.  They  are  seldom  ele- 
vated, nor  do  they  undergo  desquamation.  The  spots  first  appear 
on  the  body  as  a  rule,  but  may  be  seen  first  on  the  face.  They  soon 
become  profusely  distributed  over  the  abdomen  and  thorax,  and 
on  the  inner  surfaces  of  the  limbs.  They  present  the  character- 
istic mottled  appearance.  Sometimes  a  few  patches  may  be  found 
on  the  palms  and  soles.  The  dorsal  surfaces  of  the  hands  and 
feet  are  rarely  invaded.  The  neck  is  likewise  included  in  this  in- 
vasion. The  roseola  spots  are  of  ephemeral  duration  and  disap- 
pear very  quickly  in  the  order  of  their  appearance. 

The  duration,  however,  depends  largely  on  the  intensity  of 
their  color,  and  on  treatment. 

Diagnosis. — The  distinguishing  diagnostic  features  of  the  ery- 
thematous syphilide  are  the  form  of  the  hyperaemic  patches,  its 
color,  distribution,  and  its  characteristic  circular  or  oval  form.  The 
conditions  with  which  it  may  be  mistaken  are:  the  erythema,  fol- 
lowing the  administration  of  balsams,  mercury,  cubebs,  copaiba, 
and  the  iodides.  The  rash  which  occurs  in  scarlatina,  rubeola, 
tinea  versicolor,  pityriasis,  maculata,  roseolar  vulgaris,  and  erythema 
multiforme  may  be  often  mistaken  for  the  erythematous  syphilide. 

Treatment. — Should  they  become  pigmented,  constitutional 
treatment  must  be  supplemented  by  the  use  of  inunctions  or  fumiga- 
tions of  mercury,  otherwise  the  tonic  specific  treatment  is  all  that 
is  necessary. 

The  papular  syphilides  may  also  constitute  the  first  or  early 
symptom  of  secondary  syphilis,  or  they  may  occur  together  with 
the  erythematous  variety.  They  present  two  forms:  the  large  and 
small  flat  lenticular,  and  the  large  and  small  conical  or  miliary. 


CONDYLOMATA.  261 

which  constitute  the  dry  papular  syphilides.  Another  variety  of 
papular  syphilides  is  the  large  and  small. 

Moist  papules  occur  in  the  form  of  condylomata  and  mucous 
patches.  The  small  papules  are  about  the  size  of  a  millet  seed  or 
several  times  as  large.  They  consist  of  circumscribed  or  rounded 
elevations  of  the  skin  and  in  their  earlier  stages  are  of  a  deep  red 
color.  When  they  occur  in  the  early  secondary  stage  they  are  gen- 
eral in  their  distribution  over  the  entire  body,  including  in  its  inva- 
sion the  face  and  neck.  When  the  skin  is  the  seat  of  mucous 
patches,  the  regions  in  vi^hich  there  is  moisture,  heat,  and  friction, 
are  the  most  commonly  affected,  therefore  they  are  frequently 
found  in  the  mouth  of  the  anus,  perineum  in  the  male,  nares, 
breasts,  and  vulva  in  the  female.  When  they  occur  upon  the  scro- 
tum and  penis  they  usually  undergo  an  excoriation  and  develop 
into  condylomata. 

Condylomata. — Synonyms:  Condylomata  lata,  verruca  accumi- 
nata,  moist  wart,  and  venereal  wart. 

Condylomata  lesions  may  be  flat  or  pointed.  The  former  are 
distinctly  syphilitic,  while  the  latter  occur  in  other  venereal  dis- 
eases. They  occur  generally  as  a  consequence  of  filth,  and  most 
often  appear  about  the  vulva,  perineum,  and  anus,  owing  to  fric- 
tion and  irritation  of  adjacent  surfaces.  A  distinctive  feature  of 
these  lesions  is  their  intense  itching,  thus  characterizing  it  from 
the  other  syphilodermata. 

When  this  eruption  occurs  early  in  the  secondary  periods  it  is 
usually  symmetrical,  but  when  late,  may  be  seen  simply  in  one 
part.  If  the  lesions  are  multiple  they  are  most  frequently  unsym- 
metrical. 

The  miliary  papular  syphilide's  peculiarity  is  that  it  usually 
begins  about  the  face  and  neck,  and  is  fully  developed  at  the  end 
of  two  weeks.  This  eruption  may  be  mistaken  for  psoriasis  or 
lichen  planus. 

The  large  flat  syphilitic  papules  have  practically  the  same 
characteristics  as  the  small  papules.  They  differ  only  in  their  area 
and  are  distinctly  elevated.     These  syphilides  assume  the  so-called 


262  SECONDARY   SYPHILIS. 

copper  hue.  They  show  no  tendency  to  circular  formation  and  ordi- 
narily do  not  coalesce  except  where  there  is  friction  or  irritation. 

Diagnosis. — As  a  rule  it  is  very  easily  made.  The  only  other 
condition  for  which  it  may  be  mistaken  is  psoriasis. 

Pustular  syphilides  are  less  frequently  seen  than  the  erythem- 
atous and  papular  forms.  They  vary  in  their  size  and  intensity, 
generally  round  or  oval  in  shape,  and  surrounded  by  a  distinct 
areola.  In  their  distribution  they  may  invade  the  entire  body,  but 
sometimes  are  limited  only  to  special  regions,  having  a  tendency 
especially  for  Jiairy  parts.  The  pustules  are  more  rapid  in  their 
invasion.  Relapses  of  this  eruption  are  common.  They  are  scat- 
tered but  are  almost  invariably  symmetrical.  The  pustular  eruption 
may  appear  as  acneform  syphilides,  attacking  the  hair  and 
sebaceous,  which  are  really  papulo-pustules,  or  they  may  be  impeti- 
gofonn  or  pustulo-crustaceous  syphilides,  which  are  superficial 
lesions  with  a  tendency  to  become  serpiginous  in  character.  Again 
in  some  cases  it  may  simply  consist  of  round  superficial  pustules, 
strongly  resembling  the  eruption  of  variola,  sometimes  called  the 
variolaform  syphilides. 

The  syphilitic  ecthyma  is  another  form  of  pustular  syphilide. 
The  pustules  become  large,  and  by  desiccation  of  the  contained  pus, 
crusts  are  formed.  Their  color  is  light  brown,  and  are  round  or 
oval  in  shape.  Beneath  the  crust  is  a  well-formed  ulcer  which 
involves  the  superficial  or  deep  layers  of  the  skin.  Ecthyma  may 
appear  about  the  scalp  or  flexor  surfaces  of  the  extremities,  the 
chest  and  back,  inguinal,  abdominal,  and  gluteal  regions.  The 
deep  variety  of  syphilitic  ecthyma  occurs  usually  as  a  late  lesion 
though  it  sometimes  appears  early  especially  in  malignant  syphilis. 

Tubercular  syphilodermata  may  be  dry  or  non-ulcerative  and 
ulcerative.  They  bear  a  strong  resemblance  to  gummata.  The 
tubercle  is  more  superficial,  develops  earlier,  is  more  numerous, 
and  much  more  common  than  the  gummata.  They  develop  at  any 
period  of  the  disease  even  from  a  few  months  to  ten  years  after  the 
infection,  but  is  generally  a  tertiary  inanifestation.  These  lesions 
may  occur  at  any  part  of  the  body,  and  very  frequently  attack  the 


SYPHILIS    OF    THE    MUCOUS    MEMBRANES.  263 

face.  They  vary  considerably  in  size,  being  anywhere  from  1/2  cm. 
to  3  cm.  in  diameter.  They  appear  as  well-defined  nodules,  with  a 
tendency  to  globular  shape.  In  color  they  are  of  the  ham  or  copper 
tint.  They  form  in  a  characteristic  circle  or  sometimes  resemble 
the  letter  S,  which  is  distinctly  pathognomonic  of  syphilis.  The 
ulcerative  form  results  in  a  cicatrix  or  leaving  a  distinct  pigment  at 
the  site  of  each  tubercle.  This  occurs  especially  in  the  non-ulcer- 
ative  variety.  The  ulcerative  tubercular  syphiloderm  is  the  con- 
dition in  which  the  tubercles  degenerate  or  undergo  ulceration,  and 
may  remain  either  superficial  or  involve  the  underlying  tissue. 
When  these  remain  circumscribed,  the  crust  covered  tubercles 
surround  an  unaffected  area  of  skin.  This  circular  formation  is 
distinctly  characteristic.  In  the  more  aggravated  form  the  tubercles 
are  larger,  of  a  deep  violet  color;  after  continuing  for  a  longer  or 
shorter  period  they  inflame,  suppurate,  and  are  replaced  by  deep 
foul-smelling,  painful  ulcers.  Tubercular  syphilodermata  must 
be  distinguished  from  lupus  vulgaris,  psoriasis,  and  carcinoma. 

Pigmentary  syphilides  are  seen  in  the  form  of  various  size  areas 
or  patches  with  the  pigment,  more  or  less  distinct,  which  sooner  or 
later  undergoes  leucodermatous  changes  in  the  form  of  small  spots, 
which  gradually  increase  in  size.  This  is  called  the  retiform  pig- 
ment syphilide.  Pigmentary  syphilides  may  appear  at  any  time 
during  the  secondary  stage.  It  is  often  usually  found  during  the 
second  year  of  infection.  It  is  distinctly  an  eruption  of  the  female 
sex,  particularly  of  the  blonde  type.  (Taylor.)  It  occurs  most 
commonly  on  the  lateral  surfaces  of  the  neck,  and  the  forehead, 
rarely  invading  the  face.  The  plaques  are  well-defined,  though 
their  margins  may  be  irregular. 

The  conditions  with  which  pigmentary  syphilides  may  be  con- 
founded are  chloasma  and  tinea  versicolor.  The  situation  of  the 
eruption,  especially  when  it  occurs  on  the  lateral  surfaces  of  the  neck, 
characterizes  it  from  either  of  these  affections. 

Syphilitic  affections  of  the  mucous  membranes  in  the  second- 
ary period  are  liable  to  appear  within  four  or  five  weeks  after  the 
initial  lesion. 


264  SECONDARY   SYPHILIS. 

The  parts  usually  affected  are  the  tonsils,  palate,  pharynx,  tongue, 
cheeks,  and  lips.  Well-marked  signs  of  the  disease  frequently 
appear  at  the  anus  and  lower  part  of  the  rectum,  upon  the  foreskin, 
and  head  of  the  penis  of  the  male,  and  upon  the  vulva,  vagina,  and 
uterus  of  the  female. 

Secondary  affections  of  the  mucous  tissue  occur  in  various 
forms,  as  an  erythematous  disease,  as  a  tubercle,  or  as  an  ulcer  or 
erosion. 

Syphilitic  erythema  occurs  most  frequently  in  the  throat, 
affecting  the  arches  of  the  palate,  uvula,  pharynx,  and  sometimes 
the  root  of  the  tongue.  The  inflammation  is  either  diffused,  or 
occurs  in  distinct  mucous  patches  of  a  circular  or  oval  form. 

Ulcers  of  the  throat  generally  make  their  appearance  on  the 
uvula  and  tonsils,  arches  of  the  palate,  and  back  of  the  pharynx. 

The  superficial  ulcer  is  either  simply  an  erosion  or  an  excoriation 
cavity  with  a  well-defined,  ragged  edge,  rather  sharp  and  somewhat 
undermined.     It  usually  presents  itself  early  after  the  primary  sore. 

In  the  excavated  ulcer  the  edges  are  steep,  everted,  or  ragged,  and 
are  surrounded  by  a  hard,  inflammatory,  copper-colored  base;  the 
discharge  is  thin  and  ichorous;  the  sore  is  most  distinctly  marked 
on  the  tonsils.  They  are  liable  to  take  on  phagedenic  and  gangrenous 
action,  and  extensive  destruction  of  the  soft  palate  frequently  results. 
The  excavated  form  of  the  lesion  is  usually  accompanied  by  extensive 
swelling  together  with  great  pain  and  difficulty  in  swallowing. 
Mucous  tubercles  generally  occur  upon  the  tongue,  lips,  inside  of 
the  cheek,  tonsils,  and  palate;  they  are  slight  elevations  of  the 
mucous  surface,  usually  of  an  irregular  oval  or  elongated  shape,  and 
of  a  whitish  hue. 

Syphilis  of  the  mouth  and  the  tongue  plays  a  very  important 
role  not  only  because  it  is  a  frequent  seat  of  the  disease  but  because 
of  the  part  it  plays  in  its  transmission.  The  use  of  tobacco,  pipe 
and  cigar  holders,  eating  utensils,  etc.,  and  kissing  are  the  most 
prolific  sources  of  lesions  in  this  part  of  the  body.  Chancres  occur- 
ring in  this  region  have  been  considered  elsewhere  (see  chapter  on 
Chancre).     The  lesions  of  constitutional  syphilis  in  the  mouth  are 


SYPHILITIC   APFECTIONS    OF    THE    LARYNX.  265 

usually  superficial  and  multiple,  with  little  or  no  tendency  to  spread, 
and  are  often  symmetrical.  This  is  especially  true  when  they  occur 
in  the  early  period  of  the  disease.  Late  lesions  in  the  oral  cavities 
are  usually  solitary  and  deep  with  destructive  tendencies.  The 
type  of  lesions  which  make  their  appearance  in  the  mouth  in  a  more 
or  less  modified  term  are  macules,  papules,  tubercules,  warts, 
gummata,  and  ulcers.  These  lesions  are  naturally  of  a  moist  type, 
with  the  result  that  mucous  patches  are  by  far  the  most  frequent 
type  exhibited.  Erythema  or  syphilitic  angina  is  also  a  very  common 
specific  affection,  frequently  seen  in  the  second  stage.  In  this  neigh- 
borhood, it  is  usually  confined  to  the  fauces,  especially  in  smokers. 
It  appears  6  to  8  weeks  after  infection.  The  mucous  patches  are 
mostly  seen  on  the  tonsils,  uvula,  and  soft  palate,  sides  of  the  tongue, 
the  mucous  surfaces  of  the  lips,  and  the  buccal  membranes.  They 
are  grayish-white  in  color,  irregular  in  outline,  -and  are  not,  as  a 
general  rule,  raised  above  the  level  of  the  mucous  membrane.  They 
are  usually  quite  persistent  and  chronic  in  their  course. 

Treatment. — Applications  of  nitrate  of  silver  or  sulphate  of 
copper  solutions  15  to  20  grains  to  the  ounce.  The  mouth  and  throat 
must  be  kept  clean,  by  the  use  of  solutions  of  borax,  chloride  of 
potassium,  and  listerine.  Smoking  should  be  prohibited,  and  the 
use  of  alcohol  and  irritating  foods  interdicted.  An  application  of 
2  or  3  per  cent,  solutions  of  chromic  acid  is  also  very  serviceable  in 
these  conditions. 

Syphilitic  affections  of  the  larynx  in  the  secondary  stage  are 
erythema,  mucous  patches,  superficial  ulcerations,  and  hypertrophy. 

The  symptoms  of  any  of  these  conditions  which  may  occur  early 
or  late  in  the  secondary  stage  may  be  so  slight  as  to  escape  attention. 

Phonation  may  be  affected  to  some  extent.  Where  the  lesions  are 
ulcerated  or  where  there  is  chronic  inflammation  of  the  larynx, 
hoarseness  results  which  is  very  persistent. 

Treatment.— If  they  do  not  yield  to  internal  specific  treatment, 
spray  the  part  with  DobelPs  solution  and  cauterization  of  the 
deeper  lesions  with  nitrate  of  silver  (30  grains  to  the  oz.)  or  acid 
nitrate  of  mercury  (i-io). 


266 


SECONDARY   SYPHILIS. 


Fig.    68. — Syphilitic    alopecia.       {After  Schamberg.)      Note    the  dry  moth-eaten  ap- 
pearance. 


SYPHILITIC    AFFECTIONS    OF    THE    NAILS.  267 

Syphilitic  Affections  of  the  Hair. — The  loss  of  hair  or  syphilitic 
alopecia  is  a  very  common  symptom  of  syphilis.-  The  hair  about 
the  face  and  other  parts  of  the  body  may  be  involved  as  well  as  the 
scalp.  The  loss  of  hair  is  usually  rapid  but  rarely  permanent. 
It  may  occur  in  patches  which  are  irregular  and  without  symmetry, 
and  varying  considerably  in  size.  (Fig.  68.)  The  conditions  for 
which  syphilitic  alopecia  may  be  mistaken  are  alopecia  areata  and 
seborrhoea. 

Treatment. — Must  be  vigorous  both  locally  and  constitutionally. 
Mercurial  inunction,  frequent  shampooing  in  the  affected  area  and 
rubbed  with  an  ointment  of  resorcin  (15  grs.)  and  cold  cream 
(i  oz.).  This  application  may  be  made  night  and  morning.  White 
precipitate  (30  grs.)  to  cold  cream  (i  oz.)  is  also  an  excellent  agent 
in  this  affection. 

SYPHILITIC  AFFECTIONS  OF  THE  NAILS. 

Onychia,  invading  the  nails  primarily  and  perionychia,  the 
disease  beginning  in  the  tissues  about  the  nail  and  involving  them 
secondarily.  The  two  conditions  may  co-exist.  They  are  slow  in 
their  course  and  appear  generally  in  the  secondary  period,  but  may 
occur  much  later.  There  are  two  forms  of  onychia,  the  dry  or 
onychia  sicca,  and  the  hypertrophic.  In  the  dry  form  the  nail  is 
dull  in  color,  may  be  part  or  wholly  involved,  and  its  edge  thickened 
and  brittle.  The  surface  is  very  irregular,  causing  deformity  of 
the  fingers.  The  hypertrophic  form  which  may  involve  the  nails 
of  the  fingers  or  toes  presents  a  distinctly  thickened  condition  of  the 
nail,  very  pale  in  color,  and  the  surface  very  much  roughened  by 
minute  depressions.  Perionychia  or  paronychia  oftener  invading  the 
toes  than  the  fingers  and  involving  one  or  more  digits  (Fig.  69). 
It  generally  occurs  coincidently  with  the  appearance  of  the  syphilide 
on  the  rest  of  the  body.  There  are  three  forms  of  perionychia — 
ulcerative,  non-ulcerative,  and  a  diffused  form.  The  ulcerative 
form  appears  at  the  matrix,  as  a  small  ulceration,  or  it  may  begin  as 
a  papule  or  pustule.     The  ulceration  gradually  extends  along  the 


268 


SECONDARY   SYPHILIS. 


margin  of  the  nail,  or  under  it,  and  secretes  a  foul- smelling  pus. 
Pain  may  be  slight  or  severe.  Where  the  destruction  has  not  been 
extensive,  a  new  nail  may  appear,  which  may  be  but  slightly  de- 
formed, or  it  may  be  as  good  as  the  original  nail.     These  affections 


Fig.  69. — Diffuse  perionychia.     {Taylor.) 


of  the  nails  usually  occur  in  the  middle  aged  and  debilitated  class  of 
patients.  The  separation  of  the  nail  may  be  partial  or  complete  and 
may  occur  with  little  or  no  pain.  Syphilitic  perionychia  is  very 
persistent  in  its  course  and  may  be  attended  with  constitutional 


SYPHILITIC  AFFECTIONS  OF  THE  CORNEA.       269 

disturbances,  and  an  enlargement  of  the  axillary  glands.  The 
diagnosis  of  ulcerative  perionychia  should  not  be  mistaken  for  the 
initial  lesion. 

Treatment. — ^Vigorous  constitutional  treatment  is  always  re- 
quired in  these  affections.  The  affected  fingers  or  toes  should  be 
soaked  several  times  daily  in  hot  bichloride  solution  (i-iooo). 
Where  there  is  ulceration  or  a  destructive  tendency  cauterize  with 
acid  nitrate  of  mercury  solution  (i-io).  Again  immersing  the  part 
and  then  copiously  dusting  it  with  iodoform.  The  fingers  should 
then  be  placed  on  a  splint  and  the  arm  carried  in  a  sling. 

Syphilis  of  the  Eye  and  its  Appendages. — The  lids  and  con- 
junctiva are  very  commonly  involved  when  the  secondary  syphilides 
appear  about  the  face  or  forehead.  Alopecia  of  the  scalp  may  be 
attended  with  falling  of  the  eyelashes,  often  followed  by  a  simple 
catarrhal  conjunctivitis.  Gummata  may  develop  on  the  eye-lids 
soon  undergoing  ulceration  which  may  then  be  mistaken  for  lupus 
or  epitheHoma  as  the  auricular  glands  in  both  of  these  conditions 
are  enlarged. 

Lacr5mial  glands  may  become  involved  in  any  period  of  syphilis 
where  the  lesions,  such  as  chancres  and  syphilides,  appear  in  its 
vicinity  or  may  result  in  syphilitic  lesions  of  the  nasal  passages. 
The  symptoms  of  syphilitic  affections  of  the  lacrymal  glands  are 
pain  and  swelling  of  the  part  and  a  profuse  secretion,  sero-purulent 
in  character,  expressed  on  pressure  over  the  mass.  The  canal  may 
be  occluded  and  result  in  abscess,  periostosis,  caries,  and  necrosis. 

Treatment  is  specific  constitutional  medication  and  surgical. 

Syphilis  of  the  sclera  usually  appears  in  early  life  as  it  is  most 
frequently  a  hereditary  affection. 

Scleritis  may  manifest  itself  by  a  diffuse  or  nodular  thickening 
of  the  sclera. 

Treatment. — Consists  of  constitutional  remedies,  hot  fomenta- 
tions, dry  or  moist,  and  the  instillation  of  a  few  drops  of  atropine 
once  daily. 

Gumma  may  either  arise  primarily  or  secondarily  in  the  sclera. 

Syphilitic  affections  of  the  cornea  may  occur  as  a  paren- 


270  SECONDARY    SYPHILIS. 

chymatous  or  interstitial  keratitis.  It  is  found  most  frequently  in 
early  life,  and  is  a  characteristic  symptom  of  inherited  syphilis 
(Hutchinson) .  There  are  points  of  opacity  centrally  situated,  pale 
bluish-gray  in  color  and  scattered  through  the  deeper  layers  of  the 
cornea;  these  spots  soon  coalesce  assuming  the  haze  or  characteristic 
"ground-glass"  appearance.  Later  the  cornea  becomes  highly 
vascular.  The  corneal  opacity  then  gradually  clears  up,  beginning 
at  its  periphery.  The  course  of  the  disease  is  extremely  chronic 
with  tendencies  to  relapse,  and  usually  attacks  both  eyes.  The 
symptoms  that  are  pronounced  are  those  of  irritation,  such  as 
photophobia,  lacrymation,  pain,  and  neuralgia. 

Treatment  is  constitutional  and  local.  Instillations  of  atropine 
to  prevent  the  formation  of  iritic  adhesions.  Hot  fomentations 
and  the  eye  kept  continually  protected  from  the  light  by  means  of  a 
shade.  It  is  necessary  to  supplement  the  specific  treatment  with 
tonic  measures. 

Iritis  is  the  most  common  of  the  syphilitic  affections  of  the  eye. 
It  may  either  be  acute,  subacute,  or  chronic,  and  is  likely  to  occur  at 
any  period  of  acquired  syphilis.  Clinical  varieties  of  iritis  are  the 
plastic,  serous,  and  exudative.  Usually  but  one  eye  is  affected,  to 
which  relapses,  when  they  occur,  are  limited.  The  subjective 
symptoms  are  photophobia,  lacrymation,  pain,  and  defective  vision. 
The  objective  symptoms  are  tumefaction;  peculiar  color;  irregular 
outline  of  the  pupil,  which  may  be  oval,  jagged,  or  stellate,  due  to 
synechiae;  sluggish  reaction  of  the  iris  to  light,  and  a  deep  ciliary 
injection.  Plastic  iritis  of  early  syphilis,  the  small  nodules  forming 
at  the  pupillary  margin,  are  characteristic  of  syphilis.  Gummata 
of  the  iris  usually  lead  to  considerable  destruction  of  tissues  and 
sometimes  perforation  of  the  eye-ball. 

Treatment. — The  eye  must  be  put  at  complete  rest,  the  patient 
kept  in  a  dark  room,  the  pupil  kept  dilated  continuously  with 
atropine  solution,  and  application  of  hot  fomentations  over  the  eye. 
Counter-irritation  to  the  temple,  or  blood-letting  by  means  of  leeches 
to  the  temple  are  often  efficient  in  relieving  the  intense  pain.  The 
interocular  tension  must  also  be  carefully  watched. 


THE    OCULAR    MUSCLES.  271 

Syphilis  of  the  Choroid. — The  forms  of  inflammation  which 
affect  the  choroid  in  syphihs  are  diffuse  choroiditis,  central  choroid- 
itis, and  chronic  disseminate  choroiditis. 

Diffuse  choroiditis  involves  the  whole  choroid  and  is  sometimes 
called  chorio-retinitis.  The  chief  subjective  symptom  is  the  dis- 
turbance of  vision. 

Disseminate  choroiditis  is  a  chronic  affection.  One  of  com- 
monest forms  of  syphilitic  lesions  of  the  choroid,  is  characterized 
by  the  presence  of  numerous  ill-defined,  yellowish-while  or  reddish 
spots  of  infiltration  which  appear  beneath  the  retina  and  scattered 
through  the  fundus.  Unless  the  infiltration  encroaches  upon  the 
macula,  the  vision  is  not  necessarily  impaired. 

Choroiditis  centralis  is  characterized  by  an  exudation  which 
occurs  directly  in  the  neighborhood  of  the  macula,  causing  visual 
disturbances. 

Prognosis  in  this  condition  is  always  unfavorable. 

Treatment  consists  in  vigorous  antisyphilitic  measures  which 
will  often  obtain  marked  improvement.  Diaphoresis  and  the  appli- 
cation of  leeches  to  the  temple  is  recommended.  The  eye  should 
be  put  at  rest  and  protected  from  the  light -by  the  use  of  dark  glasses. 

The  retina  is  the  seat  of  the  following  syphilitic  affections:  i. 
simple  retinitis,  2.  exudative  retinitis,  3.  retinitis  hemorrhagica, 
and  4.  retinitis  recurrens. 

All  these  affections  are  practically  identical  in  both  their  causes, 
symptoms,  diagnosis,  and  treatment,,  as  the  syphilitic  affections  of 
the  choroid,  and,  therefore,  need  not  be  repeated  here. 

The  optic  nerve  may  be  the  seat  of  late  manifestations  of  syphilis. 
These  affections  are  papillitis,  retrobulbar  neuritis  (which  is  very 
rare)  and  optic  neuritis.  These  conditions  may  accompany  the 
severer  forms  of  syphilitic  retinitis,  or  may  come  on  in  many  cases  of 
cerebral  gumma.     Vision  may  be  rapidly  destroyed. 

Treatment  will  sometimes  be  followed  by  an  improvement  or 
cessation  of  symptoms.  These  changes  under  antisyphilitic  treat- 
ment are  significant  of  the  specific  nature  of  the  lesion. 

The  Ocular  Muscles. — ^Paralysis  of  these  muscles,  due  to  syphilis. 


272  TERTIARY   SYPHILIS. 

may  be  brought  about  in  various  ways,  such  as  from  gumma  at  the 
base  of  the  brain  pressing  upon  the  nerve  trunk  or  from  affection  of 
the  third,  fourth,  fifth,  and  sixth  cranial  nerves,  should  they  be  the 
seat  of  syphilitic  neuritis.  The  ocular  motor  paralysis  may  be 
temporary  or  prolonged  in  its  course  and  sometimes  permanent. 
Care  must  be  taken  not  to  confound  the  syphilitic  from  the  tabetic 
muscular  paralysis.  Diplopia  is  a  very  common  symptom  in  this 
affection. 

Constitutional  specific  treatment  must  be  vigorous  and  persisted 
in  until  the  process  is  controlled. 

Affections  of  the  ear  in  syphilis  are  comparatively  rare  and 
have  no  distinct  characteristics.  Gumma  may  occur  at  the  auri- 
cle. Ulcerations,  condylomata,  and  the  syphiloderma  may  occur 
on  or  about  the  external  ear. 

Affections  of  the  internal  ear  are  quite  common  in  hereditary 
syphilis,  manifesting  itself  by  deafness. 

Treatment  of  the  early  conditions  is  constitutional,  hygienic, 
diaphoretic,  and  by  blood-letting  by  means  of  cups  or  leeches.  Con- 
stitutional treatment  must  always  be  persisted  in. 

TERTIARY  SYPHILIS. 

Following  in  the  chronological  order  of  Ricord's  division  of  the 
disease,  syphilis  passes  into  the  tertiary  period  when  it  is  not  con- 
trolled and  eradicated  in  the  secondary  stage. 

Tertiary  lesions  usually  attack  the  deeper  tissues  and  therefore 
are  more  destructive  in  tendency  than  the  lesions  of  secondary 
syphilis. 

The  AFFECTIONS  OF  THE  MUCOUS  MEMBRANES  consist  in  the  for- 
mation of  ulcers,  and  mucous  patches  about  the  mouth. 

The  EYE-LIDS  are  frequently  attacked  in  tertiary  syphilis.  It 
generally  shows  itself  as  an  indurated  ulcer,  of  an  oval  shape.  The 
borders  are  inflamed  and  thickened,  and  the  conjunctiva  is  usually 
inflamed. 

Affections  of  the  periosteum  and  bones  present  themselves 


ETIOLOGY.  273 

in  the  form  of  nodes  or  gummy  tumors,  inflammatory  hypertrophy, 
.exostosis,  caries,  and  necrosis.  These  affections  may  come  on  at 
any  time  after  eighteen  months  from  the  first  affection.  They  are 
most  likely  to  occur  in  persons  of  a  scrofulous  habit,  or  whose  con- 
stitutions have  become  impaired  from  any  cause. 

The  bones  affected  with  tertiary  syphilis  are  those  that  are  super- 
ficial, or  at  least  protected  by  the  soft  parts,  as  the  tibia,  fibula, 
ulna,  clavicle,  and  bones  of  the  skull,  nose,  palate,  and  upper  jaw. 

Nodes  occur  usually  upon  the  tibia,  ulna,  clavicle,  frontal  and 
parietal  bones. 

They  are  usually  circumscribed,  semi-solid  swellings,  of  an 
ovoidal  shape,  and  slightly  elastic  to  the  touch. 

The  periosteum  and  bones  are  inflamed,  softened,  and  ulcerated, 
and  as  the  tumor  extends,  the  structures  over  the  seat  of  the  dis- 
ease become  red  and  painful,  and  ulceration  finally  takes  place  at 
the  most  prominent  point.  The  course  of  the  disease  is  chronic, 
and  it  is  attended  with  an  intermittent,  neuralgic  pain,  greatly  in- 
creased at  night. 

Caries  is  most  common  in  the  long  bones  of  the  extremities, 
in  the  skull,  and  in  the  palate,  maxillary,  nasal,  turbinate,  ethmoid 
bones,  and  vomer. 

Hypertrophy  of  the  osseous  tissue  is  exceedingly  common,  and 
may  involve  many  of  the  bones.  Those  most  liable  to  be  attacked 
are  the  tibia,  fibula,  femur,  ulna,  radius,  and  cranium.  The  tumor 
is  usually  knotty  and  irregular,  with  a  broad  base  and  a  rough 
sabrous  surface.  In  long-standing  cases  it  becomes  hard,  assum- 
ing the  consistency  of  ivory,  which  is  very  characteristic  of  syphi- 
litic osseous  affections. 

Etiology. — The  development  of  tertiary  lesions  following  the 
secondary  period  of  syphilis  is  probably  favored  by  an  impaired 
or  debilitated  constitution.  The  most  frequent  cause,  however,  of 
tertiary  syphilis  is  neglect,  improper  or  insufficient  treatment. 

The  secretions  from  tertiary  lesions  are  not  infectious. 

The  TERTIARY  SYPHiLiDES  are  gummatous,  tubercular,  serpig- 
inous, rupial,  and  the  bullous. 


2  74  TERTIARY   SYPHILIS. 

Gummatous  syphilides  always  begin  in  the  subcutaneous  con- 
nective tissue.  May  be  ulcerative  or  non-ulcerative.  Gumma  very 
frequently  develops  in  the  female  breast  and  sometimes,  though 
rare,  in  both  breasts.  The  recognition  of  gumma  is  important  so 
as  not  to  confound  it  with  epithelioma.  They  appear  very  insidi- 
ously, are  painless,  and  of  the  consistency  of  an  enlarged  lymphatic 
gland.  There  is  no  retraction  of  the  nipple,  nor  are  the  axillary 
glands  affected. 

Gummatous  ulceration  occurring  on  the  leg  is  usually  accom- 
panied with  more  or  less  oedema.     (Fig.  70.) 

Gummata  of  the  scalp  are  usually  adherent  to  the  thickened  in- 
tegument overlying  it.  The  sebaceous  or  hair  follicles  are  the  seat 
of  the  beginning  ulceration.  Sometimes  the  outer  table  of  the  skull 
becomes  enclosed.  The  invasion  is  very  slow.  The  gummatous 
secretion  has  a  very  foul  odor.  Gummatous  tumors  show  little 
or  no  tendency  to  resolution  and  are  attended  with  little  or  no  pain, 
unless  overlying  or  resting  upon  a  nerve  trunk. 

Treatment. — Constitutionally  a  vigorous  mixed  treatment  until 
the  destructive  tendency  is  checked.  Surgical  treatment  should  be 
immediate,  especially  when  there  is  a  suppurative  tendency.  Copi- 
ous dusting  with  iodoform,  or  the  application  of  mild  mercurials 
are  very  efhcient.  When  the  lesion  is  cerebral  or  spinal,  mixed 
treatment  should  be  persisted  in  and  the  dose  increased  until  the 
symptoms  are  controlled.  Sometimes  it  may  be  necessary  to  sup- 
plement the  constitutional  treatment  by  hypodermatic  injections  of 
gray  oil  or  bichloride  of  mercury. 

Tubercular  syphilides  (see  chapter  on  secondary  eruptions  for 
the  description  of  tubercular  and  pigmentary  syphilides). 

Bullous  syphilides  when  they  do  occur  are  really  the  forerunners 
of  pustules.  The  serum  which  they  contain  soon  becomes  trans- 
formed into  pus.  The  bullae  surround  a  red  areola,  and  vary  in 
size.  Desiccation  of  the  pus  soon  forms  a  dark  adherent  crust  and 
are  most  usually  found  on  the  extremities. 

Syphilitic  bullae  are  almost  invariably  of  a  late  eruption  occurring 
usually  in  debilitated  patients. 


BULLOUS    SYPHILIDES. 


275 


Fig.  70. — Ulcerating  Gummatous  Syphilide  of    the  Leg.      {After  Schamherg.) 


276  TERTIARY   SYPHILIS. 

Rupia  or  rupial  syphilide  is  an  ulcerative  lesion,  covered  by  a 
layer  formation  of  crusts,  somewhat  resembling  an  oyster-shell. 
It  is  a  late  lesion,  may  be  large  and  small,  single  and  multiple. 
Rupial  lesion  which  is  in  its  beginning  a  pustule  surmounted  with 
an  adherent  crust,  underneath  which  an  ulcerative  process  con- 
tinues increasing  the  size  of  the  lesion  with  the  progressive  formation 
of  crusts.  This  lesion  is  more  superficial  than  the  ecthyma.  Its 
outline  is  comparatively  even,  they  may  be  round  or  oval  and  may  in 
its  beginning  appear  about  the  face  or  flexor  surfaces  of  the  forearms, 
later  invading  the  rest  of  the  body,  they  are  always  more  or  less 
painful.  The  prognosis  depends  upon  the  general  condition  of  the 
patient,  if  the  lesions  are  accompanied  by  cachexia,  the  lesions  will 
usually  be  more  refractive  to  treatment.  When  the  lesions  are  very 
large  and  numerous  it  is  always  unfavorable. 

Treatment  should  be  directed  toward  the  patient  as  well  as  the 
disease. 

Constitutional  specific  treatment  must  be  vigorous  and  supple-" 
mented  by  hygienic  measures  and  tonics. 

The  serpiginous  or  wandering  syphilide  is  a  superficial  ulcer, 
involving  extensive  areas  with  the  ulceration  persistent  at  the  per- 
iphery, while  it  heals  in  the  center.  It  is  attended  with  very  little 
pain,  is  chronic  in  its  course,  may  be  superficial  or  deep,  and  is  usually 
a  large  lesion.  Superficial  variety  begins  in  the  form  of  a  pustule 
which  soon  undergoes  ulceration,  with  formation  of  thick  crusts  at 
the  periphery,  where  they  remain  adherent,  while  at  the  center  they 
separate,  leaving  healthy  granulations.  The  deep  serpiginous  syph- 
ilide, which  is  distinctly  tertiary,  begins  its  ulceration  at  the  seat  of  a 
tubercle,  ecthyma,  or  gumma.  This  ulcer  grows  quickly  and  may 
attain  considerable  size.  It  has  the  same  characteristic  as  the  super- 
ficial variety,  except  that  it  leaves  a  more  distinct  scar,  at  which 
point  there  is  often  a  tendency  to  recurrence.  Fortunately  this 
type  of  syphilide  is  rare.  It  is  very  slow  in  its  course,  sometimes 
extending  over  several  years. 

Treatment  consists  in  removal  of  the  crusts  and  treatment  of  the 


GUMMATA.  277 

ulcer.  Internally,  the  iodides  and  mercury  or  mixed  treatment 
should  be  given. 

Syphilitic  affections  of  the  tongue  in  the  late  and  tertiary 
periods  are  sclerosis  and  gummata.  Sclerosis  usually  develops 
after  the  4th  or  5th  year  of  infection.  May  be  superficial  or  deep, 
circumscribed  or  diffused,  with  no  tendency  to  ulceration  except  as 
the  result  of  injury.  Deep  sclerosis  may  be  hypertrophic  or  atrophic. 
The  atrophic  condition  is  caused  by  fibrous  contraction  of  the  new 
formed  connective  tissue. 

The  gummatous  lesion  may  be  superficial  or  deep.  The  dis- 
tinguishing traits  should  always  be  looked  for  in  establishing  a 
diagnosis  of  gumma  from  epithelioma,  glossitis  of  dental  origin,  and 
tuberculous  ulcer.  A  cancerous  process  is  composed  of  an  ulcera- 
tion seated  in  an  elevated  neoplastic  mass,  but  in  some  instances  a 
sufficiently  characteristic  elevation  does  not  exist,  because  it  has 
become  destroyed  by  the  process  of  ulceration,  and  then  one  only 
finds  a  sort  of  cavity  which  varies  in  depth.  The  base  is  indurated, 
a  most  constant  character  of  lingual  chancroid.  The  ulceration 
has  a  bad  aspect,  irregular,  sanious,  and  with  everted  edges.  The 
comparative  absence  of  pain,  even  to  mastication  and  irritant  foods, 
their  insidious  formation,  the  peculiar  involvement  of  the  lateral 
borders  of  the  tongue  near  its  tip,  and  its  appearance  at  a  much 
earlier  age,  all  point  to  a  syphilitic  lesion.  Another  distinct  feature 
of  a  gumma  is  that  it  begins  as  a  nodule  in  the  substance  of  the 
tongue.  Gummata  are  usually  multiple  and  symmetrical  and 
always  upon  the  upper  surface  of  the  tongue,  in  contradistinction 
to  carcinoma  which  are  generally  single  and  m'ay  appear  on  any 
part  of  the  tongue,  particularly  on  its  upper  surface.  Carcinomata 
are  very  vascular  and  therefore  bleed  more  readily  than  gummata. 
In  gummatous  lesions  of  the  tongue  the  submaxillary  and  sub- 
lingual adenopathy  is  absent,  whereas  in  the  malignant  lesions  it 
is  always  present.  Sections  of  the  growth  examined  by  the  micro- 
scope usually  reveal  the  nature  of  the  lesion.  One  might  be  led  to 
believe  that  with  all  these  diagnostic  signs,  mistakes  would  be  infre- 
quent, but  in  reality  it  is  often  difi&cult  to  make  a  diagnosis,  so  that 


278  TERTIARY    SYPHILIS. 

a  histologic  examination  must  frequently  be  resorted  to,  or  the 
effects  of  antisyphilitic  treatment  tried.  The  effect  of  specific  treat- 
ment is  very  significant,  but  not  always  confirmatory.  The  thera- 
peutic test  may  render  great  service.  Potassium  iodide  and 
mercury,  especially  the  latter,  should  be  given,  and  Fournier  ad- 
vises injections  of  calomel  as  this  salt  appears  to  possess  a  real 
specific  action  on  lingual  syphilitic  lesions. 

Gummatous  infiltration  of  the  soft  palate  and  pharynx  are 
attended  with  few  distinct  early  symptoms.  The  patient  may 
suddenly  lose  both  his  power  of  speech  and  of  swallowing.  The 
destructive  process  may  result  in  perforation  of  the  soft  palate  with 
a  consequent  regurgitation  of  foods  through  the  nose,  in  the  act  of 
deglutition.  The  voice  is  distinctly  nasal  and  whispering.  The 
only  other  disease  which  may  cause  this  condition  is  tuberculosis. 
The  specific  treatment  here  is  a  very  valuable  confirmatory  evidence 
in  making  the  diagnosis.  Syphilitic  ulcerations  of  the  pharynx 
usually  leave  distinct  cicatrices  in  the  forms  of  irregular  whitish 
areas  and  bands.  Here  also  the  diagnosis  of  deep  ulcerations  of 
syphilis  is  difficult  to  differentiate  from  those  of  tubercular  lesions. 
But  a  careful  history,  examination  of  the  patient,  and  the  reaction 
to  treatment,  will  usually  elicit  an  intelligent  deduction. 

Tertiary  affections  of  the  larynx  are  chronic  inflammation, 
deep  ulceration,  and  gummata. 

Chronic  inflammation  of  the  mucous  membrane  usually  gives 
rise  to  the  thickening  of  the  cords  which  may  interfere  with  respira- 
tion. MHien  ulceration  supervenes  it  results  in  a  permanent  huski- 
ness  or  loss  of  voice. 

Cancerous  affections  of  the  larynx  may  be  recognized  by  the 
extreme  pain,  its  slower  course,  and  the  characteristic  glandular 
enlargement  accompanying  malignant  lesions. 

Tertiary  affections  of  the  oesophagus  are  very  rare. 

When  ulceration  occurs,  stricture  inevitably  results,  owing  to  the 
impossibility  of  early  recognition. 

Treatment   is   purely   surgical.     Gradual   dilatation   may   be 


SYPHILIS  OF  THE  RECTUM.  279 

given  a  trial.  The  trachea  is  often  the  seat  of  gummatous  infiltra- 
tion, resulting  in  ulceration,  contraction,  and  stenosis. 

Symptoms  are  dyspnoea  and  hoarseness  of  voice. 

Syphilitic  morbid  affections  of  the  bronchi  and  lungs  are 
very  rare  and  difficult  to  diagnose.  The  liver  is  the  most  frequent 
seat  of  tertiary  lesions  of  the  viscera,  and  may  be  amyloid  degenera- 
tion, hepatitis,  and  perihepatitis.  There  are  two  forms  of  hepatitis — 
the  diffuse  and  gummatous.  The  liver  is  enlarged,  irregular,  and 
nodular,  and  may  be  attended  with  pain  which  is  either  localized 
or  diffused,  and  sharp  or  dull  in  character.  Ascites  and  albu- 
minuria may  occur,  and  where  the  condition  is  persistent,  the 
patient's  skin  may  assume  a  jaundice  hue. 

The  spleen  may  be  involved  in  the  late  period  of  syphilis,  with 
gummatous  infiltration.  The  organ  is  distinctly  enlarged  and  the 
capsule  thickened. 

Stomach  and  intestines  are  very  rarely  involved  in  syphilis 
and  are  only  found  by  microscopic  examination  of  the  suspected 
tissues,  post  mortem. 

Syphilis  of  the  Rectum. — Ulcerations  of  the  mucous  membrane, 
or  gummatous  infiltrations,  unless  they  receive  proper  treatment 
are  attended  by  a  new  connective  tissue  growth,  which  usually 
results  in  rectal  stricture. 

Prognosis. — If  found  early,  before  there  is  cicatricial  contraction, 
and  treated  properly,  both  constitutionally  and  locally,  the  ulcera- 
tive lesion  is  curable. 

Syphilis  of  the  Anus.— Chancres  may  be  seen  internal  or  ex- 
ternal in  the  outer  rim  for  a  distance  of  about  an  inch  from  the  anal 
ring.  GuMMATA  may  develop  above  the  internal  sphincter,  in 
which  case,  narrowing  or  stenosis  of  the  rectum  usually  follows. 
When  they  occur  externally,  gummata  are  usually  irregular  in  shape, 
of  a  distinctly  red  color,  are  markedly  fissured,  and  covered  with  a 
slimy  secretion.  Accompanying  the  initial  lesion  in  these  parts 
there  is  an  enlargement  of  the  inguinal  gland.  Condylomata  are 
also  very  frequently  found  at  this  point. 

Syphilitic  Affections  of  the  Muscles. — Myositis  may  occur  in 


28o  TERTIARY   SYPHILIS. 

secondary  syphilis  but  it  is  usually  an  affection  of  the  tertiary  stage. 
It  is  attended  with  rheumatoid  pain  and  an  impairment  in  the 
function  of  the  part.  When  the  condition  becomes  chronic,  there 
is  a  tendency  to  more  or  less  permanent  contraction  of  the  parts  in 
which  the  muscle  is  affected.  One  or  more  muscles  may  be  in- 
volved. The  flexors  of  the  arms,  especially  the  biceps,  are  most 
frequently  affected.  Gummatous  tumors  of  the  muscles  may  be 
superficial  or  deep,  and  usually  develop  at  the  end  of  the  muscles 
involving  the  tendons.  They  cause  very  little  pain  but  may  interfere 
with  motion  of  the  part.  The  tendinous  sheaths,  tendons  and 
APONEUROSES,  may  be  involved  primarily  or  secondarily  from  lesions 
of  neighboring  structures.  The  part  may  become  swollen,  due  to 
an  effusion  of  serum,  but  it  is  accompanied  with  very  little  pain, 
unless  it  undergoes  inflammatory  changes. 

The  BURS^  in  one  or  more  parts  may  be  the  seat  of  syphilitic 
processes  in  secondary  and  tertiary  syphilis.  The  patellae  is  a 
very  common  seat  for  this  affection.  It  is  chronic  in  its  course, 
attended  with  very  little  discomfort,  and  begins  as  a  tumor,  which 
is  hard  or  fluctuating.  Usually  found  unilateral  but  frequently 
involves  both  patellae.     The  exciting  cause  is,  as  a  rule,  traumatism. 

The  bones  are  very  frequently  the  seat  of  tertiary  lesions,  but  are, 
in  some  instances,  attacked  in  the  secondary  stage.  The  osseous 
lesions  are  osteo-periostitis,  osteo-myelitis,  and  osteitis.  Syphilitic 
osteo-periostitis  is  limited  to  the  superficial  areas  of  the  bones  and  the 
periosteum,  and  principally  attacks  the  long  bones  and  the  cranium. 
The  affected  area  may  be  cedematous.  When  the  condition  becomes 
chronic  the  bone  itself  becomes  swollen. 

Osteo-periostitis  is  a  condition  which  generally  attacks  such 
bones  as  the  tihia,  ulna,  clavicle,  and  cranium.  The  pain  which 
occurs  is  usually  attended  by  the  characteristic  nocturnal  exacerba- 
tions and  is  produced  by  the  nodes.  During  the  day  the  patient 
is  in  most  cases  comfortable. 

Exostoses  are  due  to  periostitis.  These  new  growths  are 
sometimes  movable  on  the  bone.  They  vary  in  size  and  shape, 
and  sooner  or  later  become  eburnate,  which  is  permanent. 


SYPHILITIC  AFFECTIONS  OF  THE  EPIDIDYMIS  AND  TESTIS.       28 1 

Gummatous  osteo-periostitis  commonly  occurs  in  the  long  bones, 
the  cranial  bones,  and  the  phalanges  of  the  fingers  and  toes.  Cranial 
affections  appear  as  solitary  and  multiple  nodes.  The  bones  of  the 
face  may  also  be  the  seat  of  gummatous  infiltrations.  The  inferior 
maxillary,  clavical,  scapular,  and  vertebrae  may  each  be  the  seat  of 
these  nodes. 

Syphilitic  affections  of  the  bones  is  a  rarefying  process  and  the 
bones  become  fragile.  These  syphilitic  morbid  processes  may  even 
involve  the  joints.    . 

Synovitis  frequently  occurs  and  is  seen  as  a  lesion  itself  or  from 
secondary  involvement. 

The  fingers  and  toes  are  not  uncommonly  the  seat  of  bone 
syphilis  which  affection  is  known  as  syphilitic  dactylitis.  (Fig. 
71.)  The  condition  is  very  insidious  in  its  development.  The 
patient  first  notices  slight  swelling  of  one  or  more  fingers  or  toes. 
One  or  more  phalanges  of  either  part  may  be  involved  and  sometimes 
include  the  metacarpal  or  metatarsal  bones.  Soon  the  joint  be- 
comes implicated,  flexing  the  finger.  Dactylitis  is  usually  secondary 
to  periostitis,  or  osteomyelitis.  The  condition  is  comparatively 
painless  in  most  instances.  Dactylitis  with  gummatous  infiltrations 
may  or  may  not  undergo  ulcerative  changes.  These  conditions 
result  either  in  a  thinning  or  thickening  of  the  bone  and  shortening 
of  the  finger. 

Treatment  consists  in  administering  both  the  iodides  and  mer- 
curials (mixed  treatment)  and  locally  a  mild  mercurial  ointment. 
These  measures  are  usually  followed  by  rapid  involution,  especially 
when  the  condition  is  recognized  early. 

Syphilitic  affections  of  the  epidid5miis  and  testis  may  occur 
early  or  late  in  the  disease.  The  epididymis  may  be  slightly 
increased  in  size,  usually  painless,  and  hard.  Swelling  will  be 
uniform  or  nodular,  especially  in  tertiary  syphilis,  which  in  all 
probability  is  a  gummatous  infiltration.  The  testis  may  also  be  the 
seat  of  these  hyperplastic  changes,  sometimes  involving  its  coverings. 
Tertiary  lesions  are  likewise  painless  and  appear  very  gradually. 
The  organ  becomes  swollen  and  hard  in  consistency  and  is  less 


282 


TERTIARY   SYPHILIS. 


sensitive  to  pressure  than  the  normal  testis.  Sometimes  in  syphilitic 
orchitis  there  may  be  an  effusion  into  the  tunica  vaginalis,  presenting 
the  typical  aspect  of  an  ordinary  hydrocele.     These  growths  often 


Fig.    71. — Gummata  of  the  metacarpal  and   phalangeal   bones  (dactylitis   syphilitica) 
in  a  case_of  hereditary  syphilis.      (After  Schamberg.) 


become  quite  large  and  veiy  hard.     The  complete  absence  of  pain, 
even  on  pressure,  is  characteristic.     The  course  of  this  growth  will 


last  several  vears. 


A\Tien  it  is  formed  as  gummatous  infiltration 


SYPHILITIC   AFFECTIONS    OF    THE    NERVOUS    SYSTEM.  28 


o 


this  large  fibrous  growth  may  become  nodular  and  thus  is  sometimes 
mistaken  for  tuberculosis  of  the  testis.  It  may  also  be  confounded 
with  sarcoma  of  this  organ. 

Treatment  should  consist  in  an  energetic  course  of  the  iodides  of 
mercury  in  large  doses  or  the  usual  surgical  measures.  (See 
orchidectomy  and  epididymectomy.) 

Syphilitic  affections  of  the  blood  vessels  are  aneurysm 
(principally  of  the  aorta),  phlebitis  (of  the  saphenous,  crural, 
cephalic,  and  the  basilic  veins)  and  syphilitic  endarteritis  and  arter- 
itis. (This  is  met  with  only  in  gangrene  and  gangrenous 
ulcers.) 

Syphilitic  Affections  of  the  Nervous  System. — Syphilis  may 
affect  the  nervous  system  both  in  early  and  late  periods  of  dis- 
ease. The  early  lesions  are  usually  amenable  to  treatment,  while 
the  late  lesions  (which  may  occur  as  late  as  the  20th  year  after  the 
infection)  are  more  refractory  to  treatment.  This  affection  is  more 
common  in  men  than  in  women  and  appears  more  frequently  in 
early  life. 

Affections  of  the  nervous  system  commonly  result  from  pressure 
of  osseous  lesions  or  from  syphilis  of  the  meninges.  Gummatous 
infiltrations  are  also  a  frequent  cause. 

Cerebral  Syphilis. — The  cortex  of  the  brain  is  usually  the  seat 
of  a  gummatous  infiltration,  being  either  circumscribed  or  diffused, 
in  which  instance  the  meninges  are  generally  involved.  This  con- 
dition is  spoken  of  as  meningo-syphilitis,  which  may  include  one 
or  both  hemispheres.  As'  a  result  of  syphilitic  affection  of  the 
blood  vessels,  such  as  endarteritis  obliterans,  there  may  form  small 
aneurysms.  In  consequence  of  dislodgement  of  the  embolus  or 
thrombus,  it  is  transferred  by  the  blood  current  to  a  distant  point 
where  the  various  syphilitic  processes  in  the  brain  begin.  The  sub- 
jective symptoms  commonly  met  with  are  headache,  which  should 
be  recognized  by  its  boring,  thumping,  constricting,  or  grinding 
character,  and  its  characteristic  nocturnal  exacerbations.  As  the 
condition  becomes  more  pronounced  there  may  be  mental  hebe- 
tude, stupor,  coma,  and  epilepsy.     Other  more  rare  symptoms  are 


284  TERTIARY    SYPHILIS. 

aphasia,  ocular  muscle  paralysis,  hemiplegia,  dementia,  hemianop- 
sia, and  disturbances  of  the  sense  of  taste. 

Syphilis  of  the  cord  and  meninges  and  its  coverings  become 
manifest  by  the  development  of  spastic  paralysis,  loss  of  control 
of  the  rectum  and  the  bladder,  exaggeration  of  the  tendon  reflexes, 
muscular  contractions,  and  more  or  less  analgesia.  Sometimes, 
though  rarely,  examination  of  the  eye  will  find  a  persistent  dila- 
tation of  one  pupil. 

Locomotor  Ataxia. — Sixty  to  eighty  per  cent,  of  the  cases  of 
tabes  ordinarily  met  with  are  ascribed  to  syphilitic  infection.  The 
symptoms  by  which  it  is  recognized  are  the  existence  of  the  Argyll- 
Robertson  pupil,  the  absence  of  tendon  reflexes,  lancinating  pain 
in  the  extremities,  irritability  of  the  bladder,  paraesthesia,  and  the 
ataxic  symptoms. 

Syphilitic  Cerebral  Ttimors. — These  growths  vary  in  size  and 
shape  and  may  be  single  or  multiple.  As  a  result,  there  may  be 
more  or  less  impairment  of  motion  with  a  later  development  of 
hemiplegia  and  paraplegia.  This  condition  may  follow  the  train 
of  symptoms  incident  to  cerebral  pressure  and  its  onset  may  be 
sudden.  WTien  it  is  more  gradual  in  its  onset,  the  leg  or  the  arm 
power  is  lost  first  and  then  it  gradually  involves  other  parts.  Dis- 
turbances of  sensation  or  mental  power  may  or  may  not  result. 
Mental  hebetube  is  almost  constant. 

Treatment  may  relieve  and  even  sometimes  cure.  This  depends 
largely  upon  the  age  of  the  patient  and  the  size  of  the  neoplasm. 
Syphilitic  hemiplegia  is  usually  recognized  by  two  features,  i,  that 
it  occurs  early  in  life,  and  2,  that  the  patient  rarely  loses  conscious- 
ness when  attacked.  Dementia,  the  symptom  complex  of  this  dis- 
order, includes  mental,  sensory,  and  motor  impairment.  Mental 
disorder  manifests  itself  with  intervals  of  excitation  and  gayness  of 
spirits,  alternating  with  depressions,  and  sometimes  delirium  and 
mania.  The  motor  disturbances  are  made  evident  by  the  general 
tremor  and  loss  of  coordination.  With  this  there  may  be  vertigo, 
and  visual  disturbances,  as  well  as  defective  hearing. 

The  treatment  consists  in  the  energetic  administration  of  the 


HEREDITARY    SYPHILIS.  285 

iodides,  in  addition  to  mercurials  by  the  mouth  or  by  inunction. 
Hypodermic  injections  of  the  sublimate  are  also  indicated.  The 
drug  must  be  pushed  to  the  highest  point  of  tolerance. 

Epilepsy  is  another  sequence  of  cerebral  syphilis  and  usually 
occurs  in  the  adult  suddenly  and  without  apparent  cause. 

The  diagnosis  of  syphilitic  epilepsy  is  based  on  the  history  of 
the  patient,  2,  paroxysmal  headache,  3,  the  frequency  of  mental 
disturbance,  4,  the  frequent  coexistence  of  optic  neuritis,  hemi- 
plegia, and  aphasia,  5,  age  of  the  patient,  and  6,  the  result  of  treat- 
ment.    (Taylor.) 

Malignant  syphilis  is  that  type  of  the  disease  in  which  the 
manifestations  are  of  a  virulent  type.  These  symptoms,  which  are 
often  transitory,  have  a  tendency  to  recur  in  an  aggravated  form. 
The  lesions  may  be  superficial  or  deep  seated,  and  are  more  or 
less  destructive  in  character.  This  form  of  syphilis  usually  attacks 
the  debilitated,  and  where  there  is  senility  and  alcoholism.  The 
lesions  are  as  a  rule  gummatous  and  often  undergo  ulcerative  or 
suppurative  changes,  resulting  in  paralysis,  blindness,  insanity,  etc., 
according  to  the  respective  location  of  the  growth.  Despite  its 
gravity  this  form  of  syphilis  rarely  kills. 

Syphilophobia  is  a  term  indicating  a  certain  form  of  hypochon- 
driasis in  which  the  patient,  in  whom  there  is  a  morbid  condition 
of  the  mind,  either  imagines  himself  diseased  with  syphilis  or  has 
an  intense  dread  of  syphilitic  infection. 

HEREDITARY  SYPHILIS. 

Synonyms. — Congenital  syphilis,  infantile  syphilis. 

The  symptoms  becme  manifest  during  the  third  and  twelfth 
week  after  birth.  In  instances  where  active  syphilis  exists  in  its 
early  stages,  just  prior  to  conception,  the  syphilitic  affection  of  the 
foetus  may  be  so  intense  as  to  cause  its  death. 

The  DUiiATiON  of  hereditary  syphilis  depends  upon  its  severity 
and  the  extent  of  the  lesions.  Where  the  symptoms  are  superficial 
and  mild  it  may  disappear  entirely  under  proper  treatment,  within 


286  HEREDITARY    SYPHILIS. 

a  few  months  or  a  year.  When  the  lesions  are  deep  and  extensive 
they  may  heal  under  treatment  but  recur  from  time  to  time  until 
the  age  of  puberty. 

It  is  chronic  in  its  course  and  always  more  or  less  uncertain.  The 
SYMPTOMS  do  not  appear  in  any  definite  order,  and  superficial  and 
deep  lesions  may  exist  at  the  same  time.  A  generalized  rash  ap- 
pears early,  in  which  papules,  pustules,  or  vesicles  may  be  seen 
singly  or  in  combination.  There  is  also  the  characteristic  sniffles 
and  senile  physiognomy. 

The  latter  lesions  are  more  of  the  tubercular  and  gummatous 
type.  After  about  the  third  year,  the  lesions  are  usually  deep 
seated,  affecting  the  bones,  viscera,  and  nervous  system.  In  most 
instances  the  visceral  lesions  are  intrauterine  in  origin,  possibly  the 
first  few  months,  and  which  recur  after  the  first  year.  Periostitis 
may  develop  during  the  third  and  fifteenth  year.  The  mucous 
membranes  may  be  the  seat  of  superficial  or  extensive  ulcerated 

lesion. 

The  eye  may  be  affected  between  the  4th  and  6th  year,  or  even 
up  to  the  20th  year.  The  cranium  and  teeth  may  likewise  undergo 
certain  changes. 

The  SOURCE  of  the  infection  may  be  either  from  the  father  or 
mother  or  from  both.  The  risk  of  contagion  from  either  source 
always  depends  upon  the  activity  of  the  symptoms  at  the  time  of 
conception.  When  both  parents  are  syphiUtic,  the  offspring  rarely 
escapes  infection — which  is  of  a  severe  type — and  usually  results 
in  the  death  of  the  infant.  If  the  mother  alone  has  syphiUs  (and 
fadier  is  healthy)  which  was  acquired  previous  to  conception,  the 
child  is  usually  affected.  If  the  disease  in  the  mother  was  acquired 
after  conception  had  taken  place  the  HabiUty  of  the  infection  being 
conveyed  to  the  child  is  proportionate  to  the  period  of  pregnancy 
at  the  time  of  which  the  syphilis  was  contracted.  In  the  earlier 
months  of  pregnancy  the  danger  is  greatest,  and  as  the  term  pro- 
gresses the  danger  is  less.  Syphilis  is  most  Hable  to  be  communi- 
cated to  the  foetus  during  the  secondary  period — even  up  to  four 
years  after  the  date  of  the  initial  lesion.     The  mother  being  healthy 


RETARDED    SYPHILIS.  287 

and  giving  birth  to  a  child  with  syphilis  acquired  from  the  father 
becomes  immune  against  syphiHs,  hence  Colles  law,  viz.:  "A  syphi- 
litic child  cannot  infect  its  own  mother  after  its  birth,"  consequently 
she  may  nurse  her  child  without  danger  of  contracting  the  disease 
herself.  Transmission  of  syphilis  from  parent  to  child  is 
more  probable  during  the  secondary  period  than  during  the  pri- 
mary stage.  When  the  mother  becomes  pregnant  during  the 
early  secondary  stage  and  active  treatment  has  already  been 
begun,  abortion  usually  occurs  in  from  the  third  to  the  seventh 
month.  In  cases  of  mild  infection  the  birth  of  healthy  children 
may  follow  several  infected  ones.  After  an  interval  of  about  five 
or  six  years  from  the  date  of  infection  of  the  mother,  the  risk  of 
transmission  is  very  slight. 

Von  During's  formulation  of  Colles'  law  is  as  follows:  ^'A 
healthy  woman  who,  impregnated  by  a  syphilitic  man,  has  borne 
a  syphilitic  child  may  be  free  from  all  symptoms  of  syphilitic  in- 
fection, and  may  be  considered  immune  to  syphilis."  This  obser- 
vation has  been  confirmed  by  Fournier,  Ricord,  and  other  noted 
syphilologists.  Profeta's  law. — ''A  child  born  of  a  syphilitic 
mother,  in  whom  there  are  no  evidences  of  the  disease  within  a 
reasonable  length  of  time  after  birth,  is  refractory  or  immune 
against  any  syphilitic  infection." 

Syphilis  by  Conception. — By  this  term  is  meant  that  form  of 
syphilis  in  which  the  mother  is  infected  by  the  foetus  during  preg- 
nancy, the  father  having  the  disease  at  the  time  of  conception. 

The  terms  retarded  syphilis  or  syphilis  tardo  denote  a  condi- 
tion in  which  there  is  a  delay  in  the  appearance  of  the  symptoms 
of  hereditary  infection  until  the  loth,  20th,  or  even  the  30th  year 
of  life. 

Diagnosis. — When  the  symptoms  become  manifest  they  bear  a 
strong  resemblance  to  those  of  the  tertiary  type,  and  are  difficult 
to  distinguish  therefrom.  The  history  of  the  case  may  be  the  only 
guide  to  its  hereditary  origin.  The  evolution  of  hereditary  syph- 
ilis in  a  child  apparently  healthy  at  birth  begins  with  the  charac- 
teristic snufifling. 


288  HEREDITARY   SYPHILIS. 

Signs  of  emaciation  may  make  their  appearance,  and  the  skin 
become  wrinkled  and  sallow,  and,  as  Taylor  describes  it,  the  eye 
becomes  prominent,  the  juvenile  expression  is  lost,  and  children 
look  like  little  old  men  and  women.  Simultaneous  with  this,  the 
infant  may  exhibit  the  various  skin  eruptions  on  the  face,  hands, 
feet,  and  genitals.  When  the  child  lives  to  the  3d  or  4th  year 
and  condylomata  develop,  it  is  positive  evidence  of  the  disease. 
After  the  second  dentition,  Hutchinson's  teeth  are  almost  invari- 
ably found.  The  cutaneous  eruptions  most  commonly  met  with 
are  the  erythematous  syphilides,  and  gummatous  ulcerations.  The 
testis  may  remain  small  and  there  may  be  absence  of  hair  on  the 
pubes  after  puberty.  The  mammae  also  remain  small  and  the  nose 
small  and  deformed.     The  hair  is  coarse  and  dry. 

Prognosis. — In  mild  cases  and  in  infants  at  the  breast  it  is 
favorable.  In  the  retarded  form  where  the  lesions  are  superficial 
the  outlook  is  also  good.     Where  the  eye  and  ears  are  affected,  or 

where  there  are  visceral  changes,  it  is  less 
^^^^^W'  %  favorable.  Recurrences  of  any  of  these 
M  M      Mf       >t  1     affections  are  common. 

Affections  of  the  Mucous  Membranes. 
— Coryza,  which  is  one  of  the  early  and  con- 
stant symptoms  of  hereditary  syphilis,  begins 
with    a   serous   discharge   from   the   nose. 
Fig.  72.— Hutchinson's    which    is    attended    by    the    characteristic 

Teeth.  •' 

snufSing,  especially  during  the  sleep  and  m 
the  act  of  nursing.  The  ulceration  of  the  mucous  membrane  may 
involve  the  septum,  producing  the  necrosis  with  perforation,  and 
followed  by  a  nasal  deformity. 

Mucous  PATCHES  of  the  mouth  are  also  a  very  common  hereditary 
syphilitic  affection,  and  bear  the  same  tendencies  and  features  as  in 
acquired  syphilis  of  the  adult. 

Syphilitic  affections  of  the  teeth  in  hereditary  syphiHs  are  best 
described  by  Hutchinson,  after  whom  the  affection  is  named. 
(Fig.  72.)  Of  this  malformation  which  occurs  during  the  second 
dentition,  Hutchinson  says:     "As  diagnostic  of  hereditary  syphilis 


TREATMENT.  289 

various  pecularities  are  often  presented  by  the  other  teeth,  especially 
the  canines,  but  the  upper  central  incisors  are  the  test  teeth.  When 
first  cut  these  teeth  are  usually  short,  narrow  from  side  to  side  at 
their  edges,  and  very  thin.  After  a  while  a  crescentic  portion  from 
their  edges  breaks  away,  leaving  a  broad,  shallow,  vertical  notch 
which  is  permanent  for  some  years,  but  between  20  and  30  usually 
becomes  obliterated  by  the  premature  wearing  down  of  the  tooth. 
The  two  teeth  often  converge,  and  sometimes  they  stand  widely 
apart.  In  certain  instances  in  which  the  notching  is  either  wholly 
absent  or  but  slightly  marked  there  is  still  a  peculiar  color  (a  dirty 
brownish  hue)  and  a  narrow  squareness  of  form,  which  are  easily 
recognized  by  the  practised  eye." 

Treatment  of  hereditary  syphilis  is  as  a  rule  unsatisfactory, 
owing  to  the  uncertainty  of  the  symptoms  and  lesions.  As  soon  as 
it  is  recognized,  however,  the  prevention  of  conveying  the  disease 
to  others  must  be  impressed  upon  the  parent,  and  the  instructions 
given  accordingly.  The  treatment  should  be  continued  several 
years.  Children  do  not  seem  to  be  as  easily  affected  with  intestinal 
disturbances  as  adults  from  mercurials.  The  most  popular  mer- 
curial salt,  because  of  its  being  the  best  borne,  and  productive  of  most 
good  in  infants,  is  calomel,  which  can  be  given  over  an  extended 
period  in  doses  of  1/12  to  as  high  as  1/3  of  a  grain,  three  times  a 
day  according  to  the  age  of  the  child,  and  the  severity  of  the  symp- 
toms. The  calomel  may  be  rubbed  up  with  sugar  or  milk  to  make 
it  more  palatable.  When  the  disease  is  attended  with  marked 
anaemia,  tincture  of  chloride  of  iron  should  be  given.  If  there  be 
any  gastric  or  intestinal  disturbances,  paregoric  or  a  little  Dover's 
powder  may  be  added  to  the  mercurial  preparation.  Gray  powder 
(hydrargyrum  cum  creta)  may  be  given  thrice  daily  in  doses  of  1/6 
or  1/3  up  to  2  grains  each,  combined  with  a  little  sugar  of  milk. 
Protiodide  of  mercury,  beginning  with  the  1-20  of  a  grain  and  grad- 
ually increased,  is  also  efficient,  but  must  be  combined  with  the 
Dover's  powder  to  prevent  diarrhoea  and  colic,  which  almost 
invariably  attends  its  use.  The  iodides  of  potassium  and  soda, 
given  in  doses  from  5  to  20  grs.,  three  times  daily,  to  children  a  year 
19 


290  HEREDITARY    SYPHILIS. 

or  over,  are  often  of  benefit  in  bone,  cerebral,  and  eye  lesions.  In 
very  young  infants  the  dose  should  be  about  i  gr.  and  must  always 
be  well  diluted.    (See  Chapter  on  Salvarsan,  p.  315.) 

Another  form  of  treatment  which  is  very  efficient  and  particularly 
indicated  where  there  are  osseous  and  visceral  lesions  is  giving  the 
mercury  by  inunctions.  These  are  especially  of  service  where 
there  are  no  complications,  and  should  be  persisted  in  until  the  de- 
sired effect  is  obtained.  The  ointment  may  be  spread  upon  canton 
flannel  in  the  form  of  an  abdominal  binder  and  then  carried  around 
the  child's  body,  and  worn  continually.  In  this  manner  the  child 
receives  a  uniform  amount  without  its  knowledge.  By  its  move- 
ments the  mercury  is  rubbed  into  its  skin  by  the  friction  of  its  clothes. 
Contraindications  to  the  use  of  inunctions  in  children  are  debility,  ] 
weakness  or  anaemia,  and  sleeplessness.  Mercurial  frictions  are  I 
well  borne  by  children.  The  Neopolitan  ointment  is  made  as  i 
follows:  \ 

] 

I^      Metallic  mercury 500  parts.  ^ 

Benzoinated  lard 460  parts.  i 

White  wax 40  parts.  ] 

M.     One  to  five  drams  to  be  rubbed  into  the  skin.  : 

For  an  infant,  the  ointment  should  be  rubbed  in  with  a  piece  of  \ 

flannel  on  a  different  part  of  the  abdomen  every  morning.     The  \ 

ointment  should  be  allowed  to  remain.     After  a  month  of  such  • 

treatment,  it  should  be  discontinued  for  a  week,  and  then  resumed.  : 

The  procedure  should  be  kept  up  for  a  year.     Local  lesions  may  \ 

be  treated  with:  ; 

'Bj,      White  precipitate ; 45  grs.  '] 

Petrolatum  or  olei    acid i  oz.  I 

M.     For  local  use.  I 

After  one  year's  persistent  treatment,  potassium  iodide  should 

be  given  for  3  weeks    10  days'  intermission,  then  3  more  weeks  of  t 

treatment.     Every  3   months  inunctions  should  be  resumed  for  2  ^ 

weeks.  - 


TREATMENT.  291 

Prophylaxis  is  of  the  highest  importance,  and  includes  the  care- 
ful choice  of  a  wet  nurse,  the  forbidding  of  kissing,  and  the  use  of 
cow  vaccine  exclusively  with  aseptic  instruments. 

In  hereditary  syphilis,  at  the  end  of  a  year  of  inunction,  half  to 
one  teaspoonful  may  be  given  daily  of  Gilbert's  syrup: 

I^      Mercury  biniodide gr.  iv.  ss 

Potassium  iodide 0    3 

Distilled  water o    ij 

Syr.  cinchona,  q.  s.  ad o    vj 

At  the  end  of  the  second  year,  20  centigrammes  or  3  gr.  of  potas- 
sium iodide  may  be  given  daily. 

The  liquor  of  Van  Swieten  is  sometimes  substituted: 

I^     Corrosive  sublimate i  part 

Pure    water 900  parts. 

Rectified  spirits 100  parts. 

M.     Dissolve  the  sublimate  in  the  alcohol  then  add  the  water. 
Dose  ten  drops  daily  for  each  month  of  age. 

The  prophylaxis  of  hereditary  syphilis  includes  treatment  of 
parents,  or  the  syphilitic  pregnant  woman,  discouragement  of 
marriage  between  syphilitics,  and  the  nursing  of  the  affected  child 
by  its  mother,  never  by  a  nurse.  Treatment  of  the  mother  should 
consist  in  the  iodides  and  mercury  and  begun  as  soon  as  pregnancy 
occurs  and  continued  throughout  the  entire  period  of  lactation. 
Hypodermic  injections  of  mercury  are  not  recommended  as  routine 
treatment,  as  they  are  practically  useless,  and  therefore  should  not 
be  resorted  to  except  in  emergency.  The  dose  of  bichloride  of 
mercury  given  hypodermically  is  1-32  of  a  gr.  as  a  minimum,  and 
1-8  gr.  as  a  maximum  dose. 

Treatment  of  the  coryza  consists  in  irrigations  of  the  nasal  tract, 
with  mild  antiseptic  solutions,  removing  the  mucus  and  inspissated 
material,  and  an  application  made  to  the  mucous  membrane  with 
nitrate  of  silver  solution  (i  gr.  to  the  oz.).  Treatm^ent  of  any  of 
the  other  lesions  is  the  same  as  in  the  acquired  form  of  syphilis. 


292  HEREDITARY   SYPHILIS. 

QUESTION  OF  SYPHILIS  AND  MARRIAGE. 

A  syphilitic  father  may  propagate  a  diseased  child,  or  infect  the 
mother,  by  its  conception  up  to  4  years  after  the  disease  was  con- 
tracted, hence  marriage  should  not  be  advised  unless  at  least  21/2 
years'  continuous  systematic  treatment  has  been  strictly  followed 
and  an  interval  of  at  least  a  year  elapsed  without  treatment  and 
without  any  recurrence  of  symptoms. 

TREATMENT  OF  ACQUIRED  SYPHILIS.^ 

Throughout  the  entire  course  of  treatment  of  syphilis  it  is  im- 
portant to  bear  in  mind  the  fact  that  the  patient  must  be  treated 
as  well  as  the  disease.  The  treatment  should  consist  of  hygienic, 
tonic,  dietetic,  local,  and  often  climatic,  as  well  as  anti syphilitic 
measures.  When  the  patient  presents  himself  during  the  stage  of 
of  the  initial  lesion,  he  should  be  kept  under  careful  observation  and 
his  general  health  be  put  in  the  very  best  possible  condition,  giving 
him  reconstructive  tonics  if  necessary,  correction  of  any  gastro- 
intestinal disturbances,  the  skin  kept  active  by  frequent  warm 
baths  or  sponging,  followed  by  vigorous  rubbing,  the  use  of  alcoholics 
interdicted,  unless  he  be  an  alcoholic  habitue,  in  which  instance  the 
amount  should  be  gradually  lessened.  The  use  of  tobacco  should 
also  be  prohibited.  They  should  be  instructed  to  eat  wholesome, 
nourishing,  and  easily  digestible  foods,  which  should  be  taken  at 
regular  intervals,  plenty  of  fresh  air  and  exercise,  and  indulge  in 
long  hours  of  sleep.  The  teeth  should  be  carefully  examined  so  as 
to  remove  all  local  sources  of  irritation  in  the  mouth,  sharp  edges 
should  be  made  smooth,  carious  teeth  removed  or  their  cavities 
filled,  and  the  buccal  cavities  put  in  the  best  condition  thus  elim- 
inating a  great  source  of  annoyance.  The  conditions  of  the 
kidneys  should  be  determined  at  this  time  by  microscopic  and  chem- 
ical examination  of  the  urine.  The  presence  of  oxalates,  phos- 
phates in  excess  in  the  urine,  indicating  some  impairment  of  metab- 
olism, should  be  corrected  by  suitable  diet  and  exercise.  Glyco- 
suria, if  present,  is  no  cause  for  alarm,  as  it  usually  disappears 

1  See  Chapter  on  Salvarsan  Treatment  of  Syphilis,  p.  315. 


TREATMENT    OF   ACQUIRED    SYPHILIS.  293 

under  specific  treatment.  Tendencies  toward  tuberculosis,  rheu- 
matism, gout,  catarrh,  and  affections  of  the  nervous  system  should 
be  inquired  into,  and  means  taken  to  prevent  their  develo;:ment 
during  the  course  of  treatment.  Loss  of  weight  should  be  com- 
bated by  the  usual  measures. 

The  specific  treatment  should  not  be  begun  until  the  appearance 
of  the  secondary  manifestations,  which  excludes  every  possible 
doubt  or  suspicion  of  the  nature  of  the  infection.  Of  course,  there 
are  several  exceptions  to  this  rule,  e.g.,  where  the  situation  of  the 
chancre  is  conspicuous,  where  there  is  danger  of  the  infection  being 
conveyed  to  others,  and  in  instances  in  which  there  is  interference 
in  the  function  of  a  part,  or  when  the  disease  is  acquired  during 
pregnancy. 

It  is  absolutely  futile  to  attempt  to  abort  syphilis  by  instituting 
specific  treatment,  with  the  onset  of  the  initial  lesion,  as  it  has 
been  tried  repeatedly  by  various  observers  until  it  is  now  utterly 
condemned. 

The  COURSE  of  treatment  should  be  continued  for  2  1/2  to  3 
years.  The  various  methods  of  sytemic  treatment  are:  the  con- 
tinuous or  tonic,  the  intermittent,  symptomatic,  or  expectant,  and 
the  continuous  systematic  methods.  As  to  the  mode  of  administering 
the  medicinal  remedies,  in  any  of  these  methods  they  may  be  given 
internally,  externally,  or  combined. 

Continuous  treatment,  advocated  by  Keyes  and  Hutchinson, 
may  be  briefly  described  as  follows: 

The  drug  is  pushed  to  the  point  of  tolerance,  the  dose  slightly 
reduced  until  the  active  symptoms  subside.  Tonic  dose  is  continued 
until  the  end  of  the  second  year,  then  mixed  treatment  for  the  re- 
maining 6  months. 

Symptomatic  Treatment. — Treatment  of  each  symptom,  ex- 
acerbation, recrudescence,  or  relapse  of  the  disease.  When  these 
are  controlled  tonic  treatment  is  begun,  this  form  of  treatment  is 
not  recommended. 

Intermittent  treatment  advocated  by  Fournier.  Mercury 
for  about  two  months  until  the  symptoms  are  controlled,  then  an 


294  ACQIURED    SYPHILIS. 

interval  of  2  or  3  months,  hygienic  and  tonic  measures  only  at  the 
sixth  month.  The  mercurial  treatment  is  resumed  for  another  2 
or  3  months  then  an  interval  of  3  months,  at  the  end  of  the  first  year 
or  during  the  second  year  2  or  3  courses  are  given.  Mercury  may 
be  given  by  the  mouth  but  is  slower  and  less  certain,  therefore  may 
be  insufficient  and  may  cause  stomatitis  and  gastro-intestinal  dis- 
turbances. Protiodide  is  the  best.  If  ptyalism  or  intestinal  irri- 
tation occur,  m.ercury  with  chalk  in  1/2  gr.  doses.     (Hutchinson.) 

Bichloride  1/12  gr.  may  be  used. 

The  continuous  systematic  m.ethod  as  advocated  and  taught 
by  Horwitz  is  probably  the  best  and  most  logical  plan  of  treatment 
and  will  be  considered  later. 

The  ENDERMic  METHOD,  that  by  inunction,  is  rapid,  spares  the 
gastro-intestinal  tract,  but  is  dirty  and  troublesome  and  often  causes 
eczema  and  stomatitis. 

In  the  prodromal  or  waiting  period  anemia  may  be  present,  in 
which  case  the  patient  should  be  treated  by  the  administration  of 
iron  and  arsenic.  Chloride,  and  citrate  of  iron  are  particularly  of 
value.  Basham's  mixture  and  preparations  of  peptones  of  iron  and 
manganese  are  also  of  value.  If  this  anemic  condition  persists 
with  the  onset  of  the  secondary  symptoms,  they  should  supplement 
the  specific  treatment.  Any  nervous  debility  should  be  counter- 
acted by  prescribing  extract  of  malt  to  be  taken  during  meals. 
Cod-liver  oil  is  also  of  value  in  many  cases.  Sometimes  a  sedative 
effect  of  the  nervous  system  will  be  obtained  by  the  use  of  a  gal- 
vanic current.  Insomnia  which  somietimes  occurs,  must  also  be 
attended  to.  Mucous  membranes  of  the  throat  and  mouth  should 
be  carefully  watched,  and  the  development  of  any  lesion  actively 
treated. 

Affections  of  the  scalp,  eye,  ear,  and  nails  must  be  treated  by 
direct  mercurial  medication.  The  treatment  by  the  mouth  or  by 
inunction  (preferably  the  form.er),  when  begun  in  the  early  period 
of  syphilis,  should  be  persisted  in,  alternating  it  at  definite  intervals 
with  any  of  the  methods  suggested,  which  will  be  considered  later 
in  more  detail. 


CONSTITUTIONAL    TREATMENT.  295 

CONSTITUTIONAL  TREATMENT. 

The  signal  for  beginning  the  regular  course  of  treatment  is  the 
appearance  of  the  cutaneous  syphilides  and  the  general  adenopathy. 
The  salt  which  is  most  easily  assimilated,  best  borne  by  the  patient, 
and  causing  the  least  amount  of  gastro-intestinal  disturbances  should 
be  the  one  selected  by  the  physician.  The  specific  agent  used  uni- 
versally is  mercury  which  may  be  given  by  the  mouth,  inunctions, 
by  fumigation,  hypodermatic  injections,  and  intravenous  injections. 
The  preparations  of  mercury  which  have  given  satisfaction  in  the 
therapy  of  syphilis  are  the  protiodide,  the  tannate,  the  green  iodide 
(hydrarg.  iod.  viride),  the  biniodide,  and  the  bichloride  of  mercury. 

By  the  Mouth. — The  protiodide  is  usually  given  in  the  dose  of 
1/4  to  1/2  of  a  gr.  three  times  a  day,  and  is  less  likely  to  cause  saliva- 
tion than  the  tannate.  The  use  of  calomel  and  blue  mass  are  less 
satisfactory  owing  to  their  liability  to  cause  salivation.  The  dis- 
advantage in  the  use  of  bichloride  is  that  it  very  often  produces  pain 
and  griping,  and  irritation  in  the  gastro-intestinal  tract,  when  taken 
by  the  mouth.  No  two  forms  of  syphilis  will  be  found  precisely 
alike  in  their  manifestations  and  idiosyncrasies,  therefore  no  definite 
outline  of  treatment  can  be  formulated.  It  is  easy,  however,  to  ob- 
tain information  as  to  the  patient's  tolerance  of  the  drug,  and  then 
the  principles  of  the  general  treatment  can  be  gauged  according  to 
the  virulence  of  the  symptoms.  The  initial  dose  of  the  protiodide 
of  mercury  is  1/3  of  a  grain,  but  in  most  cases  it  may  be  increased 
in  a  few  days  to  a  grain  or  i  grain  and  a  half,  or  even  more  until 
the  desired  effect  is  obtained.  Taylor  wisely  contends  that  combin- 
ing mercury  with  opium  is  extremely  dangerous,  owing  to  the  danger 
of  inducing  the  opium  habit.  Combination  of  mercury  with  iodide 
of  potassium  is  known  as  the  mixed  treatment,  and  is  valuable, 
especially  where  there  is  an  early  development  of  cerebral  symptoms 
such  as  headaches,  epilepsy,  paralysis,  etc.,  or  where  the  tertiary 
lesions  attack  the  viscera  and  deeper  structures.  The  occurrence 
of  rheumatoid  pains  and  gummatous  infiltrations,  particularly  in  the 
region  of  the  mouth,  necessitates  immed  ate  administration  of  mixed 
treatment.     This  will  be  given  consideration  later. 


296  ACQUIRED    SYPHILIS. 

After  the  degree  of  susceptibility  or  tolerance  to  the  drug  is  ob- 
tained, the  tonic  dose  is  determined  by  reducing  this  amount  just 
1/2  which  is  the  quantity  of  mercury  the  patient  is  to  continue  with 
during  the  whole  course  of  treatment.  The  susceptibility  of  the 
patient  to  mercury  must  be  determined  from  the  outset.  Begin- 
ning with  about  1/3  grain  protiodide,  three  times  a  day,  it  is  gradu- 
ally increased.  The  symptoms  which  indicate  the  degree  of  toler- 
ance to  mercury  are:  tenderness  of  the  gums  and  diarrhoea,  with 
more  or  less  colic.  When  the  tonic  dose  is  decided  upon,  a  lapse 
of  about  a  week  should  intervene  before  the  course  of  treatment 
is  begun,  so  as  to  give  the  system  time  to  recover  itself  from  the 
effects  of  the  over-dose.  After  a  course  of  six  months'  medication 
without  the  development  of  any  serious  complications,  it  is  pre- 
sumed that  the  patient  is  on  his  way  to  recovery.  Some  patients 
exhibit  untoward  effects  of  mercurials  by  the  mouth,  in  which  case 
employment  of  hypodermic  injections  of  bichlorides  of  mercury  are 
very  efficient.  Frequent  warm  baths  must  not  be  overlooked,  so 
as  to  keep  the  skin  healthy  and  active.  The  continuous  syste- 
matic course  of  treatment  is  as  follows:  At  the  end  of  the  first 
three  months  if  the  patient's  condition  is  satisfactory,  treatment 
by  the  mouth  may  be  discontinued  and  an  inunction  used  daily  for 
the  next  two  weeks,  and  then  taking  by  the  mouth  the  tonic  dose 
given,  for  the  next  three  months.  At  the  end  of  the  second  period, 
there  should  be  another  interval  of  two  weeks  during  which  time 
the  mercury  may  be  given  by  inunction  or  combined  in  small  doses 
of  iodide  of  potassium.  The  inunctions  or  hypodermic  injection  of 
mercury  are,  however,  more  preferable  during  these  intervals  as  it 
gives  the  stomach  and  intestinal  tract  a  respite  from  the  irritating 
effects  that  otherwise,  inevitably,  result  from  the  continued  use  of 
this  drug.  Sometimes  the  iodides  may  be  given  internally,  and  the 
mercury  externally  by  inunctions.  This  is  especially  indicated  in 
the  late  secondary  and  tertiary  lesions  particularly,  or  in  place  of 
the  inunction.  Hypodermic  injections  of  the  bichloride  of  mercury 
may  be  given.  When  this  is  given  in  conjunction  with  iodides  in- 
ternally it  is  also  a  form  of  mixed  treatment.     When  the  iodides 


CONSTITUTIONAL    TREATMENT.  297 

are  being  administered,  symptoms  of  iodism  and  gastric  irritations 
must  be  noted.  During  the  second  year  of  the  course  of  treat- 
ment, the  treatment  is  practically  the  same.  At  the  end  of  the  sec- 
ond year  medication  by  the  mouth  should  be  continued  the  re- 
maining six  months  on  the  mixed  treatment.  The  following  pre- 
scriptions are  of  much  value: 

I^      Hydrarg.  biniodidi gr.  ij  to  iij 

Potassi  iodidi 5  ss  to  jss 

Syr.  sarsaparilla 5  iij. 

Aquae  q.  s 5  vj. 

Sig.:     One  tablespoonful  three  times  a  day,  an  hour  after  meals. 

I^      Hydrarg.  bichloride gr.  ss  to  j 

Pottas  i  iodidi o  ss  to  j 

Essence  of  pepsin O  iij- 

Aquae  q.  s O  vj. 

Sig.:     One  tablespoonful  three  times  a  day,  an  hour  after  meals. 

At  the  end  of  2  1/2  years  the  patient  should  be  advised  to  take 
treatment  for  about  6  weeks  each  spring  and  fall  for  tiie  next  4  or  5 
years.  During  this  time  if  there  is  no  recurrence  of  any  symptoms 
he  may  be  considered  practically  cured.  Marriage  of  a  syphilitic 
should  not  be  agreed  to  by  the  physician  for  at  least  3  years  after 
the  date  of  infection.  In  the  late  secondary  and  early  tertiary 
lesions  attended  with  dry  scaling,  Donovan's  solution  (liquor  arsenii 
et  hydrargy  iodidi)  is  of  value,  in  doses  from  5  to  8  drops,  well 
diluted  with  water,  an  hour  after  eating.  Fluid  extract  of  cocoa 
and  kola  is  a  very  excellent  agent  for  its  tonic  effect  upon  the  cir- 
culatory and  nervous  system.  The  elixir  of  iron  quinine  and  strych- 
nine is  also  very  beneficial  to  the  entire  economy,  especially  where 
there  is  a  tendency  to  cachexia.  Sometimes  Basham's  mixture 
combined  with  strychnine  (1-40  of  a  gr.)  is  an  excellent  tonic. 

In  some  cases  of  syphilis  the  treatment  by  the  mouth  must  be 
actively  supplemented  by  the  use  of  hypodermic  injections,  inunc- 
tions, or  fumigations,  especially  in  infections  of  the  deeper  struc- 
tures, e.  g.,  the  bones,  joints,  nervous  system,  eye,  ear,  viscera,  and 
penis  and  testis.     In  these  cases  there  is  no  definite  formula.     The 


298  ACQUIRED    SYPHILIS. 

iodides  and  the  mercury  must  be  pushed  to  their  fullest  extent, 
even  to  the  point  of  ptyalism,  so  as  to  control  the  ravages  of  the 
disease.  As  a  rule,  patients  who  have  been  properly  advised  as  to 
the  dangers  of  the  disease,  and  impressed  with  the  extreme  im- 
portance of  their  conscientious  co-operation,  usually  react  well  to 
treatment  and  rarely  develop  any  tertiary  lesions.  The  treatment 
must  be  sulG&cient  as  well  as  eflacient. 

Mercury  by  inunctions  is  a  very  valuable  method  and  simply 
consists  in  use  of  the  official  mercurial  or  blue  ointment  of  a  strength 
of  25  to  50  per  cent.,  formula  of  which  is  as  follows: 

I^      Ungent  hyd  arg O  ij 

Vaseline  q.  s B  j 

M.     Div.  chart  No. 8  (use  oil  papers) 
Sig.:     Rub  the  contents  of  one  paper  into  the  skin  for  fifteen 
minutes,  daily  as  directed.     Ten  to  twent}"  inunctions  constitute  an 
average  course. 

It  is  best  to  begin  with  1/2  dram  either  once  daily  or  night  and 
morning.  While  the  patient  is  on  this  course  of  treatment  his 
condition  should  always  be  carefully  watched.  If  he  shows  no 
evidences  of  mercurialism,  or  other  untoward  effects,  but  on  the 
contrary  his  condition  is  benefited,  the  treatment  may  be  persisted 
in.  By  vigorous  rubbing  and  friction  with  the  hands,  the  mercury 
is  introduced  through  the  skin  by  the  way  of  the  sweat,  hair,  and 
sebaceous  follicles  into  the  lymph  spaces  and  then  absorbed.  Thus 
the  patient  receives  his  mercury,  the  stomach  is  at  rest,  and  is  in 
more  suitable  condition  for  the  digestion  of  foods,  or  other  agents 
which  the  exigencies  of  his  condition  may  require,  such  as  tonics, 
iodides,  etc.  Before  beginning  the  use  of  an  inunction,  the  patient 
should  be  carefully  instructed  to  take  a  warm  bath.  This  should 
be  followed  by  a  vigorous  rubbing  with  a  Turkish  towel,  or  where 
it  is  possible,  Turkish  or  Russian  baths  can  be  taken  in  addition 
to  these.  Should  they  disagree  with  the  patient  in  any  way,  the 
inunction  -must  be  discontinued.  The  patient  may  be  taught  to 
use  the  inunctions  himself,  or  they  may  be  given  by  a  trained  nurse 
or    masseur.     The    technic    is    as    follows:    the    contents  of  one 


CONSTITUTIONAL    TREATMENT.  299 

paper  should  be  vigorously  rubbed  into  the  skin,  employing  both 
hands,  for  15  to  20  minutes.  The  parts  of  the  body  selected  for  the 
use  of  these  rubbings  are  the  (i)  inner  surface  of  the  thighs,  (2) 
groins,  (3)  breast,  (4)  abdomen,  (5)  axilla,  (6)  arms,  (7)  popliteal 
spaces,  (8)  inner  surface  of  the  buttocks.  Parts  of  the  body  not 
covered  with  hair  should  be  given  preference.  This  should  be 
previously  thoroughly  cleansed  with  soap  and  hot  water.  At 
least  a  week  should  elapse  before  the  inunction  in  one  area  is  re- 
peated. Where  there  are  lesions,  scalp,  or  in  the  beard,  an  ointment 
composed  of  white  precipitate  (10  to  20  per  cent.),  vaseline  or  oleic 
acid  may  be  used.  Parts  should  also  be  shaved  and  subjected  to 
frequent  shampooing  and  antiseptic  lotions.  Where  the  inunctions 
produce  irritation,  such  as  dermatitis,  its  use  must  be  desisted  in 
Where  the  inunctions  in  the  ordinary  manner  are  not  practical  the 
ointment  may  be  spread  upon  a  canton  flannel  belt  and  worn  around 
the  body  and  thus  the  friction  will  be  obtained  by  the  patient 
walking  or  moving  about.  This  is  especially  adapted  to  infants 
and  children.  The  contraindications  to  the  use  of  inunctions  are: 
dermatitis,  or  other  inflammatory  skin  diseases,  stomatitis,  and 
salivation,  gastro-intestinal  disturbances,  insomnia,  debflity,  febrile 
changes,  and  rheumatoid  or  articular  pains.  During  the  course 
of  inunctions  the  patient  should  be  instructed  to  wear  the  one  set 
of  underclothing  for  the  week. 

Mercurial  fumigations  constitute  another  useful  method  in  the 
treatment  of  syphilis,  especially  during  the  secondary  and  even 
tertiary  periods,  and  in  infantile  syphilis,  but  is  less  frequently 
employed  than  in  former  years.  Fumigations  of,  or  vaporization 
of  mercury  is  useful  in  the  treatment  of  obstinate  superficial  lesions, 
either  in  the  late  secondary  or  tertiary  stage,  and  to  expedite  the 
appearance  of  the  secondary  cutaneous  manifestations.  It  is  of 
marked  benefit  in  relieving  the  osseous  and  articular  pains,  head- 
aches and  neuralgias. 

Its  disadvantage  for  practical  application  is  that  it  requires 
special  devices  and  often  expensive  appliances.  Different  methods 
may  be  extemporized  for  the  purpose,  but  is  always  troublesome 


300  ACQUIRED    SYPHILIS. 

and  takes  considerable  time.  Calomel  and  cinnabar  are  the  agents 
most  often  used.  From  20  to  60  grains  of  calomel  is  the  usual 
amount  for  each  fumigation.  Cinnabar  may  be  combined  with  it 
by  means  of  the  steam  generated  or  moist  heat,  and  together  they 
are  volatilized.  The  patient  being  stripped  and  enveloped  to  the 
neck  in  heavy  blankets,  he  is  seated  on  a  chair  with  the  lamp  under 
it.  This  should  last  20  to  30  minutes.  Then  the  patient  should 
go  to  bed,  and  covered  with  the  same  blankets  used  in  the  fumi- 
gation process.  These  baths  should  always  be  taken  several 
hours  after  meals.  The  bowels  should  be  previously  evacuated. 
The  baths  can  be  taken,  as  a  rule,  in  the  beginning,  as  often  as  three 
times  a  week. 

The  amount  of  calomel  used  depends  upon  its  effect  on  the 
patient.  If  there  are  any  signs  of  depression  after  the  bath,  the 
dose  must  be  reduced.  If  it  evidences  no  change,  it  may  be  con- 
tinued. In  most  instances,  these  must  be  continued  very  long, 
but  simply  used  to  obtain  a  therapeutic  effect.  Untoward  effects 
of  the  mercury  must  be  carefully  observed. 

Hypodermic  Injections  of  mercury. — As  a  method  of  treat- 
ment in  syphilis,  hypodermic  medication  is  applicable  in  all  stages 
and  phases  of  the  disease,  and  is  especially  valuable  for  its  rapid 
effect  in  emergency.  The  indications  for  its  use  are:  where  the 
mercury  disagrees  with  the  stomach  and  intestinal  tract,  or  where  it 
acts  as  a  depressant,  also  when  the  mercury  given  by  the  stomach 
is  followed  by  little  or  no  effect  on  the  lesions,  and  in  patients  in 
whom  there  is  an  extreme  susceptibility  to  the  drug,  even  in  small 
doses.  Hypodermic  injections  of  the  drug  are  as  a  rule  tolerated, 
therefore  it  is  a  measure  which  must  be  kept  in  reserve,  and  if  for 
any  reason  the  other  methods  fail  it  becomes  an  invaluable  substi- 
tute. Where  there  is  a  general  debility,  and  where  the  inunctions 
are  contraindicated,  the  hypodermic  method  may  often  be  used  with 
impunity.  The  best  sties  for  these  injections  are  the  interscapular 
and  post  trochanteric  regions.  When  given  in  the  gluteal  region 
the  injection  should  always  be  made  in  the  upper  outer  quadrant. 
The  best  form  of  mercury  given  by  the  hypodermic  injection  is  the 


CONSTITUTIONAL    TREATMENT.  3OI 

bichloride,  in  doses  from  1/8  to  1/2  a  grain  or  even  higher  if  necessary. 
Bichloride  solution  should  always  be  freshly  made  and  so  com- 
pounded, that  10  drops  of  distilled  water  will  represent  1/.4  of  a  grain 
of  thecontained  salt.  Commence  with  5  minims  of  a  2  per  cent,  solu- 
tion and  increase  up  to  10  or  12,  and  then  change  to  5  minims  of  a  4 
per  cent,  solution  and  increase  up  to  about  10  minims,  and  make  this 
the  maximum  dose.  The  more  concentrated  the  solution  the  less 
will  be  the  pain  and  irritation.  When  the  eruption  is  active,  use  an 
injection  every  day  until  it  has  disappeared;  but  when  the  eruption 
is  slight  or  seen  very  early,  every  other  day  usually  suffices.  The 
intervals  are  gradually  lengthened  until  by  the  end  of  about  ten 
months  only  one  injection  is  given  each  week  and  this  is  maintained 
until  the  end  of  2  1/2  or  3  years.  An  ordinary  hypodermic  syringe 
may  be  used  with  the  same  technic  as  for  other  purposes.  In- 
jections may  be  given  subcutaneously  or  intramuscularly  in  either 
instances  where  the  selected  part  is  covered  with  dense  tissues. 
The  number  and  intervals  of  the  injection  is  gauged  accordingly  in 
each  individual  case.  There  may  be  more  or  less  pain  at  the  point 
of  puncture,  or  at  the  site  of  the  injection,  with  the  sense  of  burning 
or  itching,  and  the  causing  of  distinct  firm  nodes.  Abscess,  rarely 
follow  when  the  technic  is  thorough.  The  injection  may  be  given 
intramuscularly  (gluteal  region)  and  under  the  deep  fascia  (intra- 
scapular) .  Syringe  should  be  detached  after  it  is  plunged  into  the 
tissues  to  be  ure  that  no  blood  comes  from  a  vessel.  After  the 
needle  is  withdrawn  the  part  should  be  briskly  kneaded  or  rubbed. 

Soluble  and  insoluble  salts  are  used.  The  insoluble  have  the 
advantage  of  more  persistent  effects  and  their  injections  are  only 
needed  at  longer  intervals.  The  soluble  salts  are  more  active  but 
must  be  given  daily  or  every  other  day.  Calomel  and  the  bichloride 
are  considered  by  some  as  the  best  insoluble  salts.  The  salicylate  of 
mercury  is  also  efficient  as  an  intramuscular  injection,  and  is  at- 
tended with  very  little  pain,  and  leaves  no  induration. 

The  dose  to  begin  with  is  usually  three-fourths  of  a  grain  (.04). 
The  interval  between  treatments  is  four  days.  The  dose  and 
the  length  of  the  intervals  between  the  treatments  are  gradually  in- 


302  ACQUIRED    SYPHILIS. 

creased  until  the  patient  is  taking  one  and  one-half  grains  (.09) 
weekly.  The  full  dose  of  a  10  per  cent,  preparation,  therefore,  is 
15  minims.  If  the  patient  has  been  taking  mercury  in  some  other 
manner  a  larger  dose  may  be  used  at  the  start.  In  some  cases  a 
dose  larger  than  a  grain  and  a  half  may  be  used  to  combat  special 
symptoms,  but  in  these  cases  the  more  frequent  use  of  a  soluble  salt 
of  mercury  will  probably  give  better  results.  Potassium  iodide  can 
be  administered  by  mouth  at  the  same  time. 

An  ordiiiSary  hypodermic  syringe  does  very  well.  The  needle 
should  be  at  least  one  and  a  quarter  inches  in  length  and  about  18 
caliber.  Needles  of  smaller  caliber  are  impracticable  because  the 
mercury  will  clot  in  them.  It  is  essential  that  the  needle  be  very 
sharp.  It  is  advisable  to  sterilize  the  needle  immediately  after 
use,  and  to  keep  needle,  syringe,  and  forceps  for  handling  in  an  al- 
kaline strongly  antiseptic  solution  ready  for  immediate  use  when  re- 
quired. The  outer  third  gluteal  region  is  the  usual  site  of  injection, 
alternating  from  side  to  side.  The  muscles  of  the  back  or  the 
calf  of  the  leg  may  be  used  if  desired.  The  buttock  is  cleaned, 
as  is  usual  for  hypodermic  injection. 

The  patient's  leg  is  placed  so  as  to  relax  the  gluteal  muscles, 
and  he  is  instructed  not  to  jump  when  the  injection  is  made.  The 
syringe  is  filled  with  mercury,  the  needle  is  attached,  and  air  bub- 
les  excluded.  The  needle  is  entered  firmly  and  quickly  into  the 
muscles  as  far  as  the  guard,  care  being  taken  to  avoid  injuring 
the  periosteum.  The  relations  of  the  anatomic  structures  in  the 
vicinity  should  be  borne  in  mind.  The  mercury  is  then  driven  very 
gently  and  slowly  into  the  muscles,  the  needle  quickly  withdrawn, 
and  the  part  massaged  with  a  vigorous  rotary  motion  for  one  minute 
This  massage  prevents  any  hemorrhage  from  the  puncture  hole  and 
lessens  very  materially  the  probability  of  any  soreness  or  lameness 
following.     The  author  uses  the  following  formula: 

Calom3l  may  be  employed,  viz.: 

I^     Hydrargvri  salicylatis gr.  xxx. 

Liquid-  al baline ,^  i 

Sig : — Fifteen  minims  intramuscularly  injected  equals 
I  grain. 


CONSTITUTIONAL    TREATMENT.  303 

I^      Calomel gr.  xxiv 

Glycerine 3ij 

Water oij 

Dose  5  to  15  minims  (^  to  ij  gr.),  every  5  to  15  days. 

Course  ten  to  fifteen  injections. 

Lambkin's  slightly  modified  cream  of  mercury  is  as  foUows: 

I^      Hydrarg.  (metallic) 3 j 

Lanolin,  pure 3ij 

Parolene  carbol.  1% •  •  oiv 

Of  this  5  m.  are  given  by  injection  once  a  week. 

Calomel  may  also  be  used  in  the  place  of  bichloride,  but  is  more 
liable  to  produce  salivation  and  stomatitis  than  the  bichloride. 
Gray  oil  (see  list  of  formulae  at  the  end  of  this  volume).  Hypo- 
dermic intramuscular  injections  of  the  metallic  mercury  in  the  form 
of  a  cream  as  recommended  by  Lany,  of  Vienna. 

Sodium  cacodylate  and  mercury  cacodylate  have  been  used 
in  the  various  stages  of  syphilis  with  very  gratifying  results. 

Sodium  cacodylate  is  highly  recommended  by  John  B.  Murphy 
and  others.  It  is  given  intramuscularly  in  doses  beginning  with 
one  grain  daily  and  gradually  increasing  it  in  obstinate  cases  to  as 
high  as  three  grains,  until  the  lesions  are  controlled.  It  is  surpris- 
ing in  some  cases  how  quickly  the  condition  responds  to  this  treat- 
ment. 

Mercury  cacodylate  is  given  hypodermatically  in  doses  from 
half  to  two  grains  at  intervals  of  four  to  seven  days.  It  is  best 
given  in  liquid  alb  aline. 

The  symptoms  of  mercurial  salivation  are:  soreness  in  the 
gums,  which  is  felt  particularly  in  mastication,  when  cleaning  the 
teeth  and  coming  in  contact  with  irritating  substances.  This  con- 
dition is  known  as  gingivitis.  The  gums  are  congested,  swollen, 
and  ulcerated  especially  at  the  margin  of  the  teeth,  softened  and 
tender  or  painful.  The  patient  feels  sense  of  protrusion  and  loose- 
ness of  the  teeth.  Sometimes  the  condition  may  be  so  extreme 
that  the  teeth  actually  drop  out.     They  also  complain  of  a  metallic 


304  ACQUIRED    SYPHILIS. 

taste  in  the  mouth,  the  breath  is  always  more  or  less  offensive 
The  mucous  membrane  of  the  teeth,  pharynx  and  tongue  are  con- 
gested.    Intestinal  colic  and  profuse  diarrhcea  also  accompany  this 
train  of  untoward  or  toxic  effects  of  mercury. 

The  ptyalism  may  be  so  severe  that  the  nearby  lymphatics  will 
be  found  swollen  and  painful.  This  condition  sometimes  goes  so 
far  as  to  render  it  diflScult  for  the  patient  to  open  his  mouth  or  to 
swallow,  and,  as  a  consequence,  constitutional  and  nervous  disturb- 
ances intervene.  When  there  is  a  general  mucous  involvement,  the 
condition  is  spoken  of  as  stomatitis.  The  treatment  should  be 
largely  preventive.  As  soon  as  it  is  recognized,  the  mercury  should 
be  discontinued  and  substituted  by  a  vigorous  tonic.  An  astrin- 
gent mild  antiseptic  mouth  wash  should  be  employed,  using  such 
solutions  as  chloride  tannic  acid,  potassium  of  chloride,  tincture  of 
myrrh,  common  salt,  or  boric  acid.  The  gums  may  be  touched 
with  nitrate  of  silver  or  sulphate  of  copper  solution,  5  gr.  to  the 
oz.,  or  tincture  of  iodine  or  glycerine  of  tannic  acid  applied  by  a 
cotton  swab  or  a  brush  is  of  much  benefit.  The  aim  should  be 
directed  towards  eliminating  the  mercury,  which  is  best  accom- 
plished by  diaphoretics  and  the  ingestion  and  plenty  of  milk  and 
water  as  to  keep  the  kidneys  active.  lodism,  or  the  condition  of 
the  untoward  effect  of  iodine,  instances  where  the  dose  has  either 
been  excessive,  or  where  there  exists  an  idiosyncrasy  to  the  drug. 
The  symptoms  which  may  be  mild  or  severe  are:  metallic  taste  in 
the  mouth  and  throat,  fetid  breath,  coryza,  accompanied  by  the 
typical  symptoms  of  cold  in  the  head.  The  face  may  become 
flushed  and  swollen,  also  oedema  of  the  pharynx,  epiglottis  and 
glottis,  resulting  in  hoarseness  dismar,  and  disparage  and  a  sense 
-of  burning  and  pain  in  the  throat.  Fortunately,  these  extreme  cases 
are  rarely  seen.  The  skin  may  also  manifest  the  toxic  effects  of 
the  iodides,  by  such  conditions  as  derititis  urticaria,  and  lesions 
strongly  resembling  the  secondary  syphilides.  The  digestive  func- 
tions may  be  impaired  by  the  continued  use  of  the  iodides. 

Thermal  baths  in  themselves  have  absolutely  no  specific  value 
in  the  treatment  of  syphilis.     The  hot  springs  may  be  beneficial 


THE    SERUM    DIAGNOSIS    OE    SYPHILIS.  305 

in  their  hygienic  and  mental  effects,  but  must  be  supplemented  by 
the  mercurials  or  iodides  to  obtain  any  effect. 

The  serum  therapy  of  syphilis  is  still  in  its  infancy,  but  up  to 
this  present  time  is  of  no  use  in  any  of  the  various  stages  of  the 
disease. 

Prognosis. — In  mild  cases  and  in  infants  at  the  breast  it  is 
favorable.  In  the  retarded  form  where  the  lesions  are  superficial, 
;he  out-look  is  also  good.  Where  the  eye  and  ears  are  affected,  or 
where  there  are  visceral  changes,  it  is  less  favorable.  Recurrence 
of  any  of  these  affections  are  common. 

Intravenous  injection  is  of  Bichloride  of  mercury  still  in  the 
experimental  stage.  With  the  knowledge  at  hand  its  use  is  not  to 
be  recommended. 

THE  SERUM  DIAGNOSIS  OF  SYPHILIS.^ 

The  method  of  making  an  early,  rapid  and  reliable  diagnosis  of 
syphilis  that  will  assist  our  present  clinical  knowledge,  e.g.,  the 
finding  of  the  spirocheta  pallida  in  suspicious  lesions,  etc.,  have 
been  greatly  enhanced  by  the  discovery  and  demonstration  of  cer- 
tain substances  (antibodies)  in  the  blood  serum  of  syphilitics  that 
is  of  inestimable  value,  first  because  of  its  accuracy  in  the  larger 
percentage  of  cases  and  secondly,  affording  a  means  of  confirming 
the  diagnosis  of  suspicious  lesions  not  accessible  in  any  other  way. 

In  order  to  understand  the  theory  of  Wassermann's  reaction, 
we  must  go  back,  briefly,  to  the  work  of  Bordet  and  Gengou,  who  in 
1 90 1  announced  that  they  had  succeeded  in  applying  certain 
principles  worked  out  by  them  to  the  diagnosis  of  infectious. diseases, 
especially  to  typhoid  fever.  When  bacterial  emulsions  or  vaccines 
were  injected  into  animals,  the  latter  were  rendered  immune  to  the 
particular  bacterium  used.  The  active  substances  which  were 
present  in  the  bacterial  emulsions  were  termed  antigens.  The 
animals  injected  with  these  antigens  developed  certain  defensive 

^  The  author  is  greatly  indebted  for  the  discussion  of  this  subject  to   the   excellent 
review  of  the  subject  of  Serum   Diagnosis  of  Syphilis,  by  G.  A.  Santos   Saxe,  in  the 
Amer.  Jour,  of  Urology,  Feb.,  Mar  ,  1909. 
20 


3 


Ob  ACQUIRED    SYPHILIS. 


bodies  known  as  antibodies,  in  their  serum,  in  the  process  of  be- 
coming immune  to  the  injected  bacterium. 

When  the  serum  of  an  animal  which  had  been  thus  rendered 
immune  (and  which  therefore  contined  an  antibody)  was  mixed 
with  a  bacterial  emulsion  (antigen)  of  the  same  species  of  germs  as 
had  been  used  in  immunizing  the  animal,  bacteriolysis  took  place, 
i.e.,  the  bacteria  in  the  emulsion  underwent  dissolution. 

A  further  study  of  the  antibodies  in  the  serum  of  the  immunized 
animals  revealed  the  important  fact  that  these  antibodies  were 
composed  of  two  substances  which  could  be  easily  separated  owing 
to  their  different  qualities.  These  two  substances  were  termed 
amboceptor  and  complement,  respectively.  The  amboceptor  gives  to 
the  serum  its  specific  virtues,  and  is  "thermostabile,"  i.e.,  is  not 
affected  by  heat.  It  preserves  its  properties  for  a  considerable  time, 
if  kept  in  an  ice-chest. 

The  complement,  on  the  other  hand,  is  not  a  specific  substance, 
for  it  occurs  in  all  fresh  sera,  while  the  amboceptor  is  present  in 
immune  sera  only.  The  complement  is  furthermore  destroyed  or 
"inactivated"  by  exposure  to  a  temperature  of  56°  C.  for  half  an 
hour.  If  immune  serum  is  therefore  exposed  to  this  temperature  for 
an  hour,  the  complement  is  destroyed  and  the  amboceptor  is  left.  Serum 
so  treated,  in  which  the  complement  is  lacking,  is  known  as  in- 
activated serum,  because  it  has  been  found  that  both  the  amboceptor 
and  the  complement  are  necessary  in  order  to  produce  bacteriolysis. 
When  the  complement  has  been  destroyed  the  serum  is  no  longer 
bacteriolytic.  This  is  an  extremely  important  point  and  must  be 
carefully  remembered  in  order  to  understand  what  follows.  An 
inactive  Serum  (in  which  the  complement  has  been  removed  or 
destroyed  by  heat)  can  be  rendered  active,  i.e.,  capable  of  bacteri- 
olysis (for  the  specific  bacterium  against  which  the  animal  has  been 
rendered  immune)  by  the  addition  of  fresh  serum  rich  in  comple- 
ment. The  serum  of  a  freshly  killed  guinea-pig  is  usuaUy  employed 
for  this  purpose,  as  it  is  rich  in  complement. 

We  know  now  that  bacteriolysis  cannot  take  place  without  the 
presence  of  both  amboceptor  and  complement.     If  we  remove  the 


THE    SERUM   DIAGNOSIS    OF    SYPHILIS.  307 

complement  we  find  that  the  bacteria  will  not  be  dissolved.  If  we 
then  add  complement  in  the  shape  of  fresh  guinea-pig's  serum,  we 
supply  the  second  reagent  needed  for  the  solution  of  bacteria  in 
question,  and  bacteriolysis  takes  place.  If  bacteriolysis  does  not 
take  place  after  the  addition  of  complement  (guinea  pig's  serum) 
we  know  that  the  serum  of  the  animal  tested  (containing  now  the 
amboceptor  only)  is  not  specifically  immune  for  the  bacteria  used 
in  our  test.  The  bacteriolytic  test  is  used  indetermining  the  specific 
character  of  the  serum  under  investigation.  Thus,  for  example, 
the  serum  of  a  patient  suspected  of  typhoid  fever,  which  contains 
antibodies  (amboceptor  plus  complement)  is  first  heated  to  56°  C, 
to  destroy  the  complement,  leaving  the  amboceptor.  Then  it  is 
mixed  with  an  emulsion  of  typhoid  bacilli,  and  fresh  guinea-pig's 
serum  is  added  to  supply  the  missing  complement.  If  bacteriolysis 
takes  place,  the  patient  has  in  his  serum  the  specific  antibodies  of 
typhoid  infection,  and  is  therefore  suffering  from  typhoid  fever.  If 
bacteriolysis  does  not  take  place,  the  antibodies  are  lacking,  and  the 
patient  has  not  typhoid  infection  in  his  organism. 

The  explanation  of  the  process  of  bacteriolysis,  as  given  by 
Ehrlich  and  Morgenroth,  is  that  the  specific  amboceptor  (present  in 
the  serum  of  the  animal  tested)  impregnates  the  bacteria  (antigen) 
like  a  stain  impregnates  the  germs  when  they  are  colored  for  mirco- 
scopical  study.  The  bacteria  thus  impregnated  are  rendered 
susceptible  to  the  action  of  the  complement,  which  effects  their 
disintegration  (bacteriolysis).  The  amboceptor  therefore,  while 
impregnating  the  bacteria  also  takes  hold  of  the  complement,  and 
''fixes it"  or  absorbs  it.     This  is  known  as  "complement-fixation." 

The  principles  which  have  been  thus  far  explained  apply  to 
bacterial  emulsions  or,  in  other  words,  to  a  "bacteriolytic  system" 
(inactivated  serum  plus  fiesh  guinea-pig's  serum  plus  bacteria 
(antigen)).  The  same  principtes  however  appiy  also  to  the  hemolytic 
system,  in  which  instead  of  the  bacteriat  emulsion,  red  corpuscles  are 
used.  In  order  to  understand  the  analogy  between  the  two  sets  of 
phenomena,  bacteriolysis  and  hymol}sis,  we  must  remember  that 
when  an  animal,  A,  of  one  species  is  given  injections  of  the  red 


3o8  ACQUIRED    SYPHILIS.  ■' 

blood  corpuscles  of  a  second  animal^  B,  of  a  different  species,  there 
develop   in   the  serum  of  animal  A  antibodies  which  are  specific         \ 
for,  i.e.,  which  are  capable  of  dissolving,  the  red  corpuscles  of  the 
animal  of  species  B.     Here  then  we  have  an  exact  analogy  to  the 
process  which  goes  on  when  bacteria  are  injected  into  an  animal.  \ 

The  red  corpuscles  of  an  animal  cf  a  foreign  species  act  as  antigen         | 
("generators  of  antibodies" — this  is  the  best  way  to  remember  the         i 
significance  of  this  term)  and,  when  injected,  give  rise  to  the  de-         j 
velopment  of  antibodies.     The  latter  consist  of  amboceptor  and  com-         j 
plement  in  the  same  way  as  the  antibodies  produced  in  the  bacterial         \ 
experiments,  and  the  hemolytic  ambocepter  and  complement  be 
have  in  the  same  way  as  the  bacteriolytic  substances  of  correspond-         ] 
ing  names.     Hemolysis  can  only  be  produced  when  both  amboceptor         '■ 
and  complement  are  present  together.     The  ambocepter  in  the  hemo-         j 
lytic  system  is  also  specific,  i.e.,  reacts  only  to  the  blood  corpuscles 
of  the  animal  of  the  species  used  to  inject  the  animal  tested,  and         \ 
to  no  other  blood  corpuscles.     The  amboceptor  is  not  destructible 
by  heat,  while  the  complement  is.     The  complement  can  be  found         : 
in  any  fresh  serum  in  the  same  way  as  in  the  bacteriolytic  system.  i 

Hence  we  can  utilize  a  "hemolytic  system"  to  determine  the  spe- 
cific character  of  a  serum  in  the  same  way  as  a  "bacteriolytic  sys-         I 
tern"  is  used  to  determine  the  same  specificity.     The  advantages 
of  the  hemolytic  method,  however,  is  that  it  can  be  watched  with         ; 
the  naked  eye,  as  the  solution  (hemolysis)  of  red  blood  corpuscles 
can  be  seen  to  be  complete  when  the  mixture  of  serum  and  red         . 
blood  corpuscles  grows  perfectly  clear  and  transparent,  while  any         j 
remaining  turbity  will  show  that  hemolysis  is  not  complete  or  is         ' 
absent.  j 

To  illustrate  the  way  in  which  these  principles  can  be  applied         | 
to  the  diagnosis  of  an  infectious  disease,  let  us  take  as  an  example 
a  case  of  suspected  typhoid.     We  take: 

I.  The  patient's  serum,  which  presumably  contains  antibodies 
(amboceptor  complement).  We  wish  to  test  the  specificity  of  the 
amboceptor,  and  therefore  first  destroy  the  complement  by  heating 
the  serum  to  56°  C.  for  half  an  hour. 


THE    SERUM    DIAGNOSIS    OF    SYPHILIS.  309 

2.  An  emulsion  of  typhoid  bacilli  (the  antigen). 

3.  The  complement,  i.e.,  some  fresh  serum  of  a  guinea-pig. 
Measured  quantities  of  the  above  three  substances  are  mixed  in 

a  test-tube,  and  are  allowed  to  stand  for  two  or  three  hours.  If 
the  patient's  serum  is  specific  (contains  the  specific  ambocep- 
tor) the  bacteria  will  be  dissolved,  showing  that  the  complement 
artificially  added  has  been  fixed,  i.e.,  has  combined  with  the 
amboceptor. 

In  order  to  show  that  the  complement  has  been  fixed  in  the 
above  reaction,  we  add  now  to  the  same  tube,  what  has  been 
spoken  of  above  as  a  ^'hemolytic  system,"  i.e.,  red  blood  corpus- 
cles, and  some  more  suspected  serum  which  has  been  deprived  of 
complement  by  heating  to  56°  C.  for  half  an  hour.  In  other  words. 
we  add  to  the  tube  red  blood  cells  and  amboceptor,  but  no  com- 
plement, and  the  only  complement  in  that  tube  then  is  whatever 
lias  remained  unfixed  by  the  amboceptor  before  the  addition  of  the 
red  cells. 

The  tube  is  now  allowed  to  stand  and  is  examined  from  time  to 
time.  If  hemolysis  occurs,  we  know  that  there  had  been  no  bacteri- 
olysis, in  other  words,  the  complement  had  remained  free  and  has 
united  with  the  amboceptor  added  with  the  hemolytic  system  and 
the  red  cells  to  produce  hemolysis.  If  the  complement  has  re- 
mained free  and  there  was  no  bacteriolysis  the  serum  under  exami- 
nation was  not  a  typhoid  serum,  as  the  amboceptor  of  a  typhoid 
serum  is  specific  (bacteriolytic)  for  the  emulsion  of  typhoid  bacilli, 
in  the  presence  of  complement. 

On  the  other  hand,  if  hemolysis  is  absent,  it  means  that  the  com- 
plement had  been  fixed  in  the  bacteriolytic  system  and  that  there 
had  been  bacteriolysis  in  the  tube.  The  patient  therefore  has 
typhoid  fever. 

In  other  words,  and  to  state  the  matter  very  briefly,  hemolysis 
under  these  conditions  shows  an  absence  of  specific  antibodies  in 
the  serum  of  the  patient,  while  the  absence  of  hemolysis  shows  the 
presence  of  specific  substances,  and  therefore  the  presence  of  a  specific 
infection. 


3IO  ACQUIRED    SYPHILIS. 

Wassermann's  test  for  syphilis  is  an  application  of  these  prin 
ciples  to  the  .serum  diagnosis  of  syphilis.  The  only  essential  dif- 
ference between  Wassermann's  test  and  the  reaction  for  typhoid 
introduced  by  Bordet  and  Gengou  is  that  since  we  cannot  culti- 
vate the  SpirochcBta  pallida,  we  use  as  an  antigen  in  this  reaction 
extracts  of  the  internal  organs,  (liver)  of  syphilitic  newly-born  which 
contain  the  active  agent  or  virus  of  syphilis.  Wassermann,  Neis- 
ser  and  Bruck  were  the  first  to  experiment  with  the  extracts  of 
organs  of  syphilitic  subjects,  and  announced  the  fact  that  it  was 
possible  to  apply  the  reaction  of  Bordet  and  Gengou  to  the  diag- 
nosis of  syphilis.  They  experimented  with  the  syphilitic  serum  of 
both  apes  and  men  and  found  that  non-syphilitic  serum  did  not 
interfere  with  hemolysis,  while  syphilitic  serum  did.  A  positive 
Wassermann  reaction  therefore  consists  in  the  persistence  of  turbidity 
(hemolysis  absent  or  incomplete)  under  the  same  conditions  as  were 
described  above  for  typhoid  fever  save  that  instead  of  the  emulsion 
of  typhoid  bacilli  an  extract  of  syphilitic  liver  is  used. 

In  the  orignial  method,  Wasserman  used  extracts  of  syphilitic 
organs  made  with  salt  solution.  Wasserman,  Forges  and  Meier, 
Landsteiner,  MUer  and  P„tzl,  Levaditi  and  Yamanouchi  working 
independently,  found  that  extracts  made  with  alcohol  also  contained 
the  antigen  and  could  be  used  to  produce  the  reaction. 

Wasserman  suggested,  in  view  of  the  solubility  of  the  active 
constituents  of  syphilitic  livers,  that  the  antigens  must  be  closely 
alHed  to  the  lipoid  bodies,  such  as  lecithin,  cholesterin,  etc.  Ac- 
cordingly, Forges  and  Meier  began  to  use  solutions  of  lecithin, 
instead  of  the  alcoholic  extracts  of  syphilitic  organs,  as  antigens 
in  Wasserman's  test.  Alm^ost  simultaneously- several  other  auth  rs 
reported  successful  experiments  in  the  same  direction  with  a  variety 
of  similar  chemical  substances.  Levaditi  used  sodium  gLxocho- 
late;  Sachs  and  Altmann  used  sodium  oleate;  Fleischmann  used  vase- 
lin  and  cholesterin.  Other  substances  such  as  glycogen,  sodium, 
taurocholate,  etc.,  were  used. 

While  working  with  lipoids,  Sachs  and  Altm^ann  found  that  the 
reaction  of  the  serum  had  something  to  do  with  the  result  of  the 


THE    SERUM   DIAGNOSIS    OF    SYPHILIS.  3 II 

test.  They  were  able  to  prevent  the  fixation  of  the  complement  by 
adding  a  sufficient  amount  of  dilute  sodium  hydrate  solution,  and 
by  adding  properly  diluted  hydrochloric  acid,  they  were  able  in 
to  some  cases  charge  a  negative  test  to  a  positive. 

An  interesting  confirmation  of  the  hypothesis  that  the  active 
syphilitic  substance  in  the  extracts  of  organs  used  in  the  Wasser- 
mann  test  was  a  lipoid,  and  found  in  the  researches  of  Beneke  who 
noted  great  numbers  of  large,  fat  droplets  in  the  livers  of  syphil- 
itic children,  which  stained  deeply  with  Loeffler's  methylene  blue 
solution.  These  drops  of  fat  are  covered  with  a  membrane  of  soapy 
material,  which  is  invisible  without  the  stain.  Fat  drops  in  nor- 
mal livers  do  not  stain  in  the  same  manner.  This  soap  membrane, 
according  to  Beneke,  is  composed  of  a  lipoid  substance. 

Forges  and  Meier's  Simplified  Method. — Of  the  various 
methods  of  employing  lipoids,  which  have  been  referred  to,  that 
of  Forges  and  Meier,  worked  out  under  Wasssrman's  direction, 
has  attracted  most  attention.  Finding  that  lecithin  worked  well 
as  an  antigen  in  the  syphilis  reaction.  Forges  and  Meier  simplified 
the  method  of  serum  diagnosis  by  mixing  equal  parts  of  a  0.2  per 
cent,  suspension  of  lecithin  in  distilled  water  and  of  the  serum 
of  a  suspected  patient  in  a  test  tube,  and  allowing  to  stand  for 
five  hours.     If  the  serum  is  syphilitic,  a  floccubnt  precipitate  forms. 

The  percentage  of  pv:/sitive  results  is  far  too  great  in  tuberculosis 
to  make  the  method  of  Forges  andMeier  safe. 

Klausner's  Method. — Klausner  showed  that  he  could  obtain  a 
reaction  with  distilled  water  when  mixed  with  the  serum  of  syphilitic 
patients.  He  found  in  fifty  examinations  in  both  syphilitics  and 
non  syphilitics  that  distilled  water  gave  a  very  distinct  precipitate  in 
the  former  within  fifteen  hours. 

Klausner's  method  is  exceedingly  simple,  but  unfortunately  is 
also  the  least  trustworthy  of  the  methods  suggested  thus  far. 

The  method  which  Noguchi  employed  for  detecting  an  increase  of 
the  protein  in  the  cerebrospinal  fluids  affords  a  much  sharper  and 
more  enduring  means  of  differentiating  normal  from  paralytic  spinal 
fluid  than  the  Nonne  method  of  half-saturation  with  ammonium  sul- 


312  ACQUIRED    SYPHILIS. 

phate.  It  is  very  simple  and  can  be  made  with  small  quantities  of 
material  in  less  than  half  an  hour.  Its  diagnosis  value  has  been 
found  to  be  equivalent,  if  not  superior  to  that  of  cytological  ex- 
amination.    The  technic  of  this  method  is  as  follows: 

To  O.I  c.c.  of  spinal  fluid  add  0.4  c.c.  of  the  10  per  cent,  butyric 
acid  (specimens  which  has  been  preserved  in  the  refrigerator  for 
about  one  year,  or  those  from  which  all  cellular  elements  have 
previously  been  removed  by  centrifugalization,  are  equally  good  for 
the  test).  Boil  briefly  over  a  flame,  then  add  quickly  o.i  c.c.  of 
normal  solution  of  sodium  hydroxide  and  reheat  briefly.  Allow  the 
test-tube  to  stand  in  a  frame  and  observe  the  reaction.  Read  the 
reaction  for  diagnosis  aften  ten  to  twenty  minutes;  longer  standing, 
extending  to  several  hours,  offers  no  advantage,  and  the  character- 
istic appearance  of  the  reaction  become  less  obvious  after  the  lapse 
of  this  time.  In  the  spinal  fluid  from  cases  of  general  paralysis  cere- 
brospinal lues,  tertiary  lues,  and  tabes,  a  coarse  granular  orflocculent 
precipitate  appears,  which  gradually  settles  down  to  the  bottom 
of  the  test-tube  leaving  the  fluid  above  clear.  In  the  spinal  fluid 
from  cases  of  alcoholic  psychoses,  dementia  praecox,  and  epi- 
lepsy, as  well  as  from  normal  subjects,  there  occurs  a  slightsand 
diffiise  opa  escence  only,  and  no  coarse  precipitate  forms  even  after 
several  hours.  In  case  of  an  ambiguous  reaction  a  test  with  0.2  c.c. 
of  the  spinal  fluid  must  be  made,  and  this  usually  decides  the  point. 

Up  to  the  present  the  cases  tested  with  the  Wassermann  method, 
and  the  estimate  of  positive  results  in  syphilitics  varies  from  80 
to  95  per  cent. 

Negative  reactions  have  been  obtained  in  about  15  per  cent,  of 
cases  with  manifest  syphilis.  This  circumstance  should  be  borne  in 
mind  in  interpreting  negative  serum  reactions,  and  in  no  case  should 
a  patient  be  declared  free  from  syphilis  because  the  reaction  is 
found  negative. 

A  positive  reaction,  so  far  as  we  know  from  results  up  to  date 
simply  means  as  Wassermann  states:  "That  syphilis  exists,  either 
past  or  present;  not  necessarily  as  an  active  process." 

Influence  of  Treatment  upon  the  Wassermann  Reaction. — 


THE    SERUM   DIAGNOSIS    OF    SYPHILIS.  313 

Inasmuch  as  Wassermann's  reaction  is  assumed  to  be  dependent 
upon  the  presence  of  antibodies  in  the  serum  of  a  syphilitic  patient, 
the  natural  assumption  would  be  that  treatment  by  means  of  mer- 
cury, salvarsan,  etc.,  would,  if  carried  on  to  a  sufhcient  degree,  event- 
ually so  combat  the  infection  that  the  organism  no  longer  would  de- 
velop antibodies.  In  other  words,  patients  who  have  been  treated 
sufficiently  would  show  a  negative  reaction,  while  those  in  whom 
treatment  was  insufficient  and  who  threaten  to  develop  further  le- 
sions, or  who  are  carriers  of  unseen  syphilitic  lesions,  would  show 
a  positive  reaction.  If  this  were  so,  the  prognosis  and  the  need 
of  treatment  could  be  regulated  simply  by  applying  the  serum 
reaction. 

The  influence  of  treatment  upon  the  reaction  is  not  quite  clearly 
established.  For  want  of  a  better  standard,  the  need  of  treat- 
ment may  be  assumed  when  the  reaction  is  positive,  reserving  our 
right  to  change  this  view  when  more  definite  date  on  this  subject 
are  at  hand.  Above  all,  we  should  beware  of  advising  a  patient  to 
marry  on  the  strength  of  a  negative  Wassermann  reaction,  even  if  re- 
peatedly performed,  unless  this  patient  fulfils  the  old  requirements 
of  a  sufficient  number  of  years'  treatment. 

NoGUCHi  Butyric  Acid  Method  Test. — Up  to  the  present 
what  seems  to  be  the  most  satisfactory,  accurate,  and  trustworthy 
modification  of,  or  rather  substitute  for,  the  complicated  Wasser- 
mann reaction,  is  a  method  devised  by  Noguchi  who  bases  his 
method  upon  the  fact  that  the  active  substances  in  the  patient's 
serum  which  enter  into  the  phenomena  of  the  Wassermann  and  the 
Porges-Meier  reactions  are  members  of  the  globulin  group.  Accord- 
ing to  Elias,  Neubauer,  Porges,  and  Salmon,  these  substances  are 
present  both  in  normal  and  syphilitic  sera,  differing  only  in  the 
quantities,  which  are  greater  in  the  latter  than  in  the  former. 

In  order  to  simplify  this  method  still  more  and  to  make  it  available 
for  the  practitioner,  avoiding  the  tedious  weighing  of  the  globulin 
deposit,  Noguchi  devised  a  method  of  indirect  estimation  of  the 
globulins  by  precipitation  with  weak  solutions  of  acids.  The  follow- 
ing is  the  technic  which  he  recommends  for  this  purpose. 


314  ACQUIRED    SYPHILIS. 

Take  o.  5  c.c.  of  serum  and  mix  it  with  4.  5  c.c.  of  a  half-saturated 
solution  of  ammonium  sulphate  (prepared  as  above  described). 
Centrifuge  the  precipitate  for  thirty  minutes,  using  an  ordinary 
laboratory  centrifuge.  The  rate  of  revolutions  should  be  as  high 
as  possible,  but  it  is  not  necessary  to  use  as  high  as  5,000.  It  is 
sufficient  if  the  precipitate  is  solid  enough  to  allow  decantation  of 
the  supernatant  fluid.  After  the  latter  has  been  poured  away, 
the  deposit  of  globulins  is  mixed  with  5  c.c.  of  a  o.  9  per  cent,  salt 
solution.  This  dissolves  the  deposit.  Take. one  part  of  a  60  per 
cent,  butyric  acid  with  five  parts  of  a  o.  9  per  cent,  solution  of  sodium 
chloride.  This  makes  a  10  per  cent,  solution  of  absolutely  butyric 
acid.  Of  this  solution  of  butyric  acid,  mix  an  equal  volume  with 
the  solution  of  globulins  deposited  in  the  centrifuge  tube.  Shake 
the  mixture  well  and  allow  to  stand  at  room  temperature.  Observe 
the  tube  from  time  to  time.  If  the  serum  is  normal  there  is  as  a 
rule  no,  or  at  most  slight  opalescence,  even  at  the  end  of  two  hours 
from  the  time  of  acidification.  With  the  globulin  solution  from 
syphilitic  serum,  which  gives  positive  Wassermann's  test,  a  dense 
cloudiness  arises  in  the  mixture  promptly,  and  within  thirty  minutes 
or  a  little  later,  it  becomes  flocculent  and  finally  a  deposit  in  the 
bottom  of  the  test-tube  occurs. 

The  results  obtained  by  means  of  the  methods  of  globulin  estima- 
tion indicate  that  an  increase  in  the  globulin  content  is  parallel  by  the 
positive  results  of  the  Wassermann  test.  The  indirect  globulin 
method,  however,  gives  slightly  higher  percentage  of  positive  results. 
Among  the  control  patients,  the  sera  from  normal  individuals  and 
from  gonorrhoeal  patients  gave  invariably  negative  results.  Of  the 
rest  of  the  controls,  four  cases  showed  an  increase  of  globulin  and 
also  reacted  positively  to  the  Wassermann  test,  but  a  syphilitic 
infection  could  not  be  excluded  in  these  cases. 

Noguchi,  furthermore,  applied  a  similar  method  to  the  diagnosis 
of  cerebrospinal  fluids .  In  43  cases  of  general  paralysis  and  of  tabes 
he  obtained  100  per.  cent,  positive  results,  showing  that  there  is  a 
closer  relation  between  the  increase  of  leucocytes  and  that  of  globu- 
lins than  between  the  increase  of  globulins  and  the  positive  reaction 


THE    SALVARSAN    TREATMENT    OF    SYPHILIS.  315 

to  the  Wassermann  test.  In  other  words,  the  results  obtained  by 
cytological  diagnosis  and  globulin  estimation  are  in  good  harmony, 
while  the  Wassermann  reaction  was  in  some  instances  absent, 
although  the  globulin  was  increased.  In  43  cases,  37  showed 
positive  Wassermann  reactions.  In  2  of  40  control  cases,  where 
the  globulin  tests  were  all  negative,  the  Wassermann  reaction  was 
faintly  positive. 

THE   SALVARSAN  TREATMENT  OF  SYPHILIS.^ 

Salvarsan,  or,  as  it  is  commonly  known,  "606,"  recently  dis- 
covered by  Ehrlich,  has  been  received  with  much  acclaim  by  the 
medical  profession  throughout  the  entire  world.  Its  use  has  been 
attended  with  variable  results,  and  the  question  of  its  permanent 
effects  is  still  an  open  one,  not  sufficient  time  having  elapsed  to  come 
to  any  definite  conclusions.  Its  chemical  name  is  ''diamidodioxy- 
arsenobenzolhydrochloride."  It  is  an  arsenic  compound  which 
combines  the  most  intense  spirillo-tropic  properties  with  the  very 
mildest  possible  toxic  (organo-tropic)  action.  In  other  words,  a 
substance  which  was  so  specific  for  given  parasites  as  to  completely 
destroy  them  at  one  injection  but  which  was  at  the  same  time  harm- 
less to  the  person  himself.  The  antisyphilitic  action  of  this  com- 
pound was  first  noted  by  Hata  in  syphili:ic  rabbits,  but  its  first  use 
in  the  treatment  of  human  syphilis  is  credited  to  Alt  and  his  assist- 
ants Hoppe  and  Schreiber. 

Salvarsah  is  a  pale  yellow  powder  and  because  of  it  becoming 
speedily  oxidized  is  put  up  by  the  manufacturers  in  sealed  glass 
tubes  in  the  presence  of  nitrogen.  It  is  soluble  in  hot  water  and  a 
perfectly  clear  solution  of  a  greenish-yellow  color  may  be  obtained 
by  dissolving  0.6  gramme  of  the  substance  in  8  c.c.  of  distilled 
water  (acid  solution).  If,  to  this  acid  solution,  sodium  hydrate  be 
added,  a  gelatinous  precipitate  forms,  which  upon  further  addition 

*  The  author  is  indebted  to  Professor  E.  Tomasczewski's  excellent  article  "A  Re- 
view of  the  Salvarsan  Treatment  of  Syphilis,"  Ameriran  Journal  of  Urology,  March, 
191 1. 


3l6  ACQUIRED    SYPHILIS. 

of  the  alkali,  again  disappears,  leaving  a  perfectly  clear  solution, 
yellow  in  color  (alkaline  solution). 

The  alkaline  solution  is  recommended  by  most  authorities.  If 
only  a  small  amount  (2.5  or  3.0  c.c.)  of  normal  2  or  3  per  cent, 
sodium  hydrate  is  used,  intramuscularly,  it  does  not  give  rise  to 
extensive  infiltrates  nor  acute  pains  that  invariably  occur  when 
larger  amounts  of  sodium  hydrate  solution  is  used. 

Neutral  Emulsions. — Wechselmann  and  Michaelis  have  en- 
deavored to  introduce  a  ''neutral  emulsion."  Michaelis  dissolved 
the  substance  in  hot  distilled  water  and  added  enough  sodium 
hydrate  solution  to  obtain  a  perfectly  clear  alkaline  solution.  He 
then  added  two  or  three  drops  of  a  0.5  per  cent,  alcoholic  solution  of 
phenolphthalein  (red  color)  to  serve  as  an  indicator  for  the  subse- 
quent neutralization  with  i  per  cent,  acetic  acid.  When  this  acid 
was  added,  salvarsan  is  precipitated  in  the  shape  of  yellow  flakes. 
By  shaking  steadily  and  adding  acetic  acid  drop  by  drop,  the  red 
color  is  made  to  disappear,  showing  that  the  solution  has  been 
neutralized. 

Wechselmann  dissolves  the  substance  first  in  i  or  2  c.c.  of  15  per 
cent,  sodium  hydrate  solution.  He  next  adds  glacial  acetic  acid, 
drop  by  drop,  until  a  fine  yellow  mud  is  precipitated.  The  latter  is 
suspended  in  i  or  2  c.c.  of  sterile  distilled  water,  and  then  is  tested 
with  litmus  paper.  If  the  reaction  is  acid,  it  is  neutralized  with 
decinormal  sodium  hydrate  solution;  or  with  i  per  cent,  acetic  acid, 
if  the  reaction  is  alkaline.  The  neutral  suspension  is  then  centrifuged 
for  the  purpose  of  removing  the  sodium  acetate  which  nas  formed 
during  the  process  of  neutralization.  The  clear  fluid  is  decanted 
from  the  precipitate  in  the  centrifuged  tube,  and  the  remainder 
is  suspended  in  from  4  to  6  c.c.  of  sterile  physiologic  salt 
solution. 

Oily  Suspensions. — Kromayer,  Volk  and  others  have  devised 
and  recommended  suspension  of  salvarsan  in  oily  media,  such  as 
liquid  paraffin,  olive  oil,  oil  of  sweet  almonds,  etc.  These  mixtures 
are  prepared  by  finely  triturating  the  substance  in  a  mortar  with  a 


THE    SALVARSAN    TREATMENT    OF    SYPHILIS.  317 

little  oil;  or  paraffin.  Usually,  5  or  6  c.c.  of  oil  or  liquid  paraffin  arc 
employed  to  each  dose  of  salvarsan. 

Subcutaneous  injection  of  a  neutral  emulsion  had  been  found  dis- 
appointing. Even  the  proper  execution  of  a  subcutaneous  injection 
is  difficult,  even  in  the  hands  of  experts.  Furthermore,  there  is 
considerable  pain  afterwards  for  several  days  or  weeks. 

Intramuscular  Injections.  Local  Effects. — The  fact  that 
inflammatory  foci  which  tend  to  necrose,  are  formed  in  the  vicinity  of 
the  injected  mass,  is  dependent  upon  the  chemical  constitution  of 
salvarsan.  Reactions  occur  in  muscles  as  well  as  in  the  subsucta- 
neous  tissues,  with  this  difference,  that  in  the  muscles  the  conditios 
for  absorption  seem  to  be  more  favorable,  and,  therefore,  the  rule  is 
that  intramuscular  injections  usually  terminate  in  cicatrization, 
while  the  formation  of  abscesses  which  point  outward,  is  exceedingly 
rare.  The  intensity  of  the  reaction,  furthermore,  depends  upon  the 
individual  injection.  We  find  the  same  differences  in  employing 
soluble  and  insoluble  mercurial  injections.  In  this  mannner,  we  can 
explain  the  great  differences  in  the  local  reaction  which  occurred  in 
individuals  in  spite  of  the  fact  that  the  method  of  injection  was  the 
same  in  all  cases.  Naturally,  the  site  of  the  injection  has  also  some- 
thing to  do  with  the  intensity  of  the  reaction.  If  the  injection  be 
made  in  the  neighborhood  of  the  sciatic  nerve,  then  the  formation 
of  the  infiltrate  which  followed  the  injection,  may  give  rise  to  severe 
pain,  and  even  paralysis,  due  to  the  irritation  of  the  sciatic  nerve. 

The  injections  should  therefore  always  he  administered  in  the  upper 
external  quadrant  of  the  buttocks,  and  the  needle  should  not  be  intro- 
duced too  deeply  in  thin  persons. 

Lesser's  Method. — Take  a  graduated  cylinder  with  ground 
stopper.  Add  ^^606"  salt;  immediately  add  15  c.c.  hot  water, 
shake  vigorously  until  every  particle  of  the  salt  is  dissolved;  then  add 
2  c.c.  normal  sodium  hydrate  (NaOH)  solution;  a  precipitate  occurs. 
Then  continue  to  add  sodium  hydrate  solution  in  very  small  quantity, 
shaking  vigorously  after  each  addition,  until  the  solution  begins 
to  clear;  then  drop  by  drop,  until  we  have  clear  solution.  This 
should  be  neutral;  if  the  cylinder  does  not  contain  20  c.c.  of  solution, 


3i8 


ACQUIRED    SYPHILIS. 


Sterile  water  is  added  up  to  that  amount.     Then  lo  c.c.  of  this  solu- 
tion is  injected  deep  into  the  buttocks  on  either  side,  always  taking 
care  to  cleanse  the  parts  with  soap,  water  and  iodin. 
Intravenous  Injections. — These  are  preferred  by  an  increasing 

number  of  workers,  not  because 
they  act  better,  but  because  they 
do  not  give  rise  to  any  local  re- 
action, can  easily  be  repeated,  and 
seem  to  be  especially  intensive  in 
their  effects  when  used  in  conjunc- 
tion with  intramuscular  injections. 
Boehm  describes  his  method  of 
giving  salvarsan  intravenously  as 
follows: 

Two  graduated  glass  containers 
of  250  c.c.  capacity  are  used. 
(The  author  uses  containers  made 
on  the  principle  of  the  thermos 
bottle  to  keep  a  uniform  degree  of 
heat.)  Into  one  is  poured  150  to 
200  c.c.  of  sterile  salvarsan  solu- 
tion. The  other  is  filled  with  a 
like  volume  of  sterile  saline  solu- 
tion (made  with  sterile  distilled 
water  and  chemically  pure  sodium 
chlorid).     (See  Fig.  73.) 

The  saline  solution  is  allowed 
to  flow  out  of  the  needle  so  as  to 
expel  all  air  from  the  tube.  The 
stop-cock  is  now  reversed,  allow- 
ing the  salvarsan  solution  to  flow 
out  of  the  needle,  thereby  expel- 
ing  all  air  from  its  respective  tubing.  The  stop-cock  is  now  re- 
versed to  its  formicr  position,  until  the  saline  solution  is  running 
in  a  slow  even  stream  from  the  needle.     The  desired  site  of  punc- 


FlG. 


73. 


THE    SALVARSAN    TREATMENT    OF    SYPHILIS.  319 

ture  is  selected  on  the  arm  or  at  the  elbow,  and  the  needle  is  gently 
pushed  or  thrust  through  the  skin  into  the  vein.  Meanwhile  the 
saline  solution  is  continuously  running  from  it.  The  needle  is  held 
at  about  an  angle  of  10  to  15  degrees  to  the  skin  surface,  depending 
on  the  prominence  and  caliber  of  the  vein.  Care  must  be  exer- 
cised not  to  push  the  needle  through  both  walls  of  the  vein.  This 
can  be  avoided  by  not  introducing  too  long  a  surface  of  the  needle 
into  the  tissues. 

The  patient  previously  has  his  arm  carefully  cleansed,  a  ligature 
in  the  form  of  an  ordinary  soft  rubber  catheter  or  tubing  is  tied 
around  the  middle  of  the  arm,  above  the  selected  site  of  puncture, 
and  the  patient  is  requested  to  tighten  the  fist,  to  make  the  super- 
ficial veins  more  prominent.  Some  prefer  to  expose  the  vein  in  all 
cases. 


As  soon  as  the  needle  has  entered  the  vein,  the  rubber  ligature 
is  released  by  an  assistant,  the  stop-cock  of  the  needle  is  reversed, 
and  the  salvarsan  solution  flows  through  the  needle  into  the  vein. 
Hence,  there  is  no  danger  of  any  salvarsan  solution  getting  into 
the  subcutaneous  tissues.  No  injection  should  be  given  intraven- 
ously in  less  than  about  ten  minutes,  and  the  solution  must  be 
quite  warm  when  poured  into  the  container  so  as  to  allow  for  its 
cooling  when  poured  into  the  apparatus;  when  it  enters  the  vein, 
the  solution  should  be  about  the  temperature  of  the  blood.  An 
ideal  intravenous  injection  is  painless. 

The  needle  (see  Fig.  74)  will  not  produce  cramping  of  the  hand  of 
the  operator  as  the  thumb  and  middle  fingers  pass  through  the  rings, 
and  the  index-finger  rests  on  the  corrugated  plate  on  its  superior 


320  ACQUIRED    SYPHILIS. 

surface,  thus  affording  firm  support  and  preventing  the  needle 
from  changing  position  after  it  has  entered  the  vein,  which  may 
occur  if  the  patient  coughs  or  sneezes.  It  affords  a  firm  and 
comfortable  hold,  even  if  the  operator  wears  rubber  gloves. 

Another  advantage  of  this  needle  is  that  the  stop-cock  is  readily 
adjusted.  While  the  needle  is  being  introduced  into  the  vein,  blood 
must  not  be  allowed  to  flow  out  of  the  vein  and  enter  the  tube 
containing  the  salvarsan  solution.  Blood  entering  the  needle  at 
any  time  except  when  the  saline  solution  is  constantly  flowing  out 
of  the  needle  would  have  a  tendency  to  clot  in  it  quickly  and  block 
its  lumen. 

According  to  Jadassohn,  there  is  frequently  a  trace  of  albumin 
in  the  urine.  In  some  cases  there  were  transient  symptoms  of  a 
hemorrhagic  nephritis.  Frequently  there  is  an  oliguria  of  short 
duration,  with  a  polyuria  following. 

Bladder  disturbances  have  been  noted  in  a  number  of  cases. 
Difficult  urination,  transient  or  moderately  prolonged  urinary  re- 
tention, vesical  tenesmus.  The  origin  of  these  vesical  disturbances 
is  still  in  dispute. 

Injections  of  salvarsan  quite  frequently  give  rise  to  skin  erup- 
tions. Usually  these  eruptions  occur  in  the  first  days  after  injec- 
tions, are  accompanied  by  rise  of  temperature  and  disappear  rap- 
idly. As  a  rule,  these  eruptions  are  erythematous  or  urticarious, 
rarely  hemorrhagic.  In  some  cases  the  eruption  occurs  only  after 
a  repetition  of  the  injection  (Wechselriian,  Jahassohn). 

It  is  noteworthy  that  the  skin  eruptions  peculiar  to  arsenic,  have 
been  seen  but  rarely  after  the  use  of  salvarsan.  Keratosis  has 
never  been  noted,  while  arsenical-zoster  has  been  reported  in  but 
a  few  cases.  (Ledermann,  Bettmann,  and  others.)  Marked  pig- 
mentations (melanoses)  are  also  very  rare,  but  it  might  be  noted 
that  the  eruptions  of  the  earlier  stages  of  syphilis  have  a  tendency 
to  heal  with  a  more  brownish  discoloration  than  we  are  accustomed 
to  see  in  mercurial  treatment. 

The  so-called  late  eruptions  (Wechselmann,  Goldbach)  occupy  a 
special  position,  and  present  a  very  characteristic  clinical  picture. 


THE    SALVARSAN    TREATMENT    OF    SYPHILIS  32 1 

After  a  chill,  the  temperature  rises  and  may  remain  for  several 
days  in  succession.  At  the  same  time,  there  appears  a  measles 
or  scarlet-fever-like  eruption,  frequently  accompanied  by  red- 
ness and  swelling  of  the  phar}'ngeal  ring,  \Yith  or  without 
false  membranes.  The  patients  complain  of  headache,  feel  miser- 
able and  are  sometimes  temporarily  in  a  state  of  depression.  The 
pulse  is  usually  very  small  and  very  frequent.  .All  these  cases 
have  thus  far  terminated  favorably.  After  live  or  eight  days  the 
fever  disappears,  the  eruption  vanishes,  often  with  desquamation, 
and  the  patient  feels  well.  Abortive  cases  also  occur.  For  a  few 
days  low  temperatures  are  noted  and  the  eruption  rapidly  fades. 
In  other  cases,  the  patient  merely  feels  very  ill.  It  has  been  re- 
peatedly noted  that  these  late  eruptions  occur  in  conjunction  v^dth 
renewed  painful  swellings  at  the  sites  of  injection.  Possibly,  these 
eruptions  may  be  due  to  the  action  of  toxic  derivatives  of  salvarsan 
which  have  formed  in  these  deposits.  Thus  far,  these  late  eruptions 
have  not  been  noted  after  intravenous  injections. 

The  conclusion  from  all  this  is  that  salvarsan  is  by  no  means  an 
indifferent  remedy.  On  the  other  hand,  it  has  been  shown  by  the 
rarity,  the  mildness  and  the  rapid  disappearance  of  nearly  all  the 
general  effects  that  have  been  obser^'ed  thus  far,  that  the  dose  of 
0.5  or  o.  6  grammes  is  relatively  non- toxic  and  that  but  very  few 
Jiuman  beings  have  a  congenital  idiosyncrasy  for  salvarsan.  It  is 
questionable  whether  this  holds  good  for  repeated  injections.  In 
this  respect,  we  lack  sufl&cient  experience.  \\&  know,  however, 
quite  surely  that  one  injection  does  not  seem  to  produce  a  specific 
hypersensitiveness. 

The  Elimixatiox  of  Salvarsax. — After  intravenous  injections 
the  elimination  of  appreciable  amounts  of  arsenic  in  the  excreta  is 
terminated  within  four  or  live  days.  After  subcutaneous  and 
intramuscular  injections  the  elimination  is  prolonged  to  six  to  eight 
days,  (Fischer  and  Hoppe),  or  for  fourteen  or  eighteen  days,  ac- 
according  to  Greven.  Very  small  amounts  of  arsenic  may  be 
demonstrated  in  the  urine  for  a  number  of  weeks,  provided  a 
deposit  is  present. 


322  ACQUIRED    SYPHILIS.       ^ 

The  Mortality  or  Salvarsan.  Contraindications. — Deaths 
have  been  reported  after  injections  of  salvarsan.  The  contraindica- 
tions against  the  use  of  the  remedy,  as  follows:  Serious  disturbances 
of  the  circulatory  organs.  (Even  compensated  cardiac  lesions  are 
contraindications  for  intravenous  injection.)  Cases  with  degenera- 
tion of  the  blood  vessels,  aneurisms,  transient  cerebral  hemorrhages, 
patients  with  irritable  cardiac  and  nervous  systems,  old  persons 
with  advanced  degeneration  of  the  central  nervous  system,  par- 
ticularly cases  of  marked  locomotor  ataxia  and  progressive  paralysis, 
cases  with  fetid  bronchitis,  with  severe  diabetes,  even  when  the  urine 
does  not  give  any  acetone  reaction,  severe  nephritis,  gastric  ulcers,  all 
forms  of  cachexia,  which  are  not  directly  due  to  syphilis,  and  finally, 
all  cases  which  have  been  treated  with  any  of  the  arsenic  compounds, 
even  when  they  have  been  employed  a  year  or  more  previously. 

In  addition,  it  is  well  to  exclude  from  salvarsan  treatment,  for 
the  present,  all  cases  of  specific  affections  of  the  eye,  the  optic  nerve, 
the  eye-muscles,  etc.  Disturbances  in  the  internal  ear  in  the  acous- 
tic nerve,  should  also  be  contraindications  of  salvarsan  treatment, 
especially  all  cases  which  have  shown  symptoms  of  an  affection  of 
the  labyrinth  aften  one  injection  of  salvarsan. 

Therapeutic  Eeeects. — The  effect  of  salvarsan  upon  the  mani- 
festations of  syphilis,  can  no  longer  be  disputed  by  anyone.  Nearly 
all  forms  or  primary,  secondary  and  tertiary  syphilis  yield  with  re- 
markable promptness  to  this  treatment.  An  enormous  mass  of 
clinical  material  gathered  during  the  last  few  months,  demonstrated 
this.  Some  forms,  however,  require  further  discussion.  Thus, 
the  swollen  lymph  nodes,  especially  in  the  primary  stage,  diminish 
very  slowly  in  size.  The  large  papular  eruptions  also  showed 
quite  frequently  a  sluggish  response  to  treatment,  while  the  acne- 
like and  small  papular  syphilides  usually  disappear  rapidly.  The 
secondary  syphilitic  affections  of  the  mouth  and  throat  disappeared 
rapidly,  and  without  any  traces,  save  in  rare  exceptions.  The  same 
is  true  of  the  various  tertiary  lesions.  The  tertiary  affections  of 
the  bones  and  joints,  particularly,  are  affected  favorably  by  this  treat- 
ment.    The  most  brilliant  results,  however,  are  noted  in  the  so- 


THE    SALVARSAN    TREATMENT    OF    SYPHILIS.  323 

called  precocious  tertiary  forms,  the  malignant  forms  of  syphilis, 
whether  they  affect  the  skin  or  the  nose  and  throat,  as  they  often  do. 

At  first,  it  was  feared  that  salvarsan  would  not  be  applicable 
in  congenitally-syphilitic  children.  The  effects  of  a  sudden  destruc- 
tion of  such  large  numbers  of  spirochsetae  in  this  form  of  syphilis, 
it  was  feared,  would  react  unfavorably.  Ehrlich  himself  expressed 
this  doubt.  Experience  showed,  however,  that  salvarsan  could  be 
employed  even  in  the  first  weeks  and  months  of  life,  and  that  the 
results  were  excellent.  The  best  summary  of  this  subject  was  that 
of  E.  Lesser.  ^'  Of  nine  children,  between  the  ages  of  five  and  twelve 
weeks  who  had  been  treated  by  salvarsan,  none  died,  while  in  the 
years  1908  and  1909,  there  had  been  ten  deaths  among  twenty-seven 
cases  between  the  same  ages,  a  mortality  of  almost  40  per  cent. 
The  spirochaetae  disappear,  the  symptoms  improve  and  the  children 
develop  in  a  normal  manner." 

It  might  be  noted  here  how  slight  a  reaction  is  produced  in  the 
body  of  an  infant  when  spirochaetae  perish  in  it  in  such  masses.  In 
these  infants  there  are  neither  symptoms  referable  to  an  intoxication 
due  to  the  swamping  of  the  body  with  toxins  which  have  been  set 
free,  nor  is  there  any  remarkable  high  elevation  of  temperature. 

The  success  with  salvarsan  treatment  in  older  patients  with 
congenital  syphilis  with  parenchymatous  keratitis  have  been  but 
slight. 

After  the  astonishing,  sometimes  quite  remarkable  results  ob- 
tained with  salvarsan  in  almost  all  lesions  of  acquired  and  congenit 
tal  syphilis,  it  seemed  natural  that  attempts  should  be  made  to  treas 
with  this  remedy  the  so-called  meta-syphilitic  affections — tabee 
dorsalis,  and  progressive  paralysis.  Some  reason  for  this  might  bf 
traced  to  the  fact  that  Alt,  to  whom  the  credit  must  be  given  os 
having  first  applied  salvarsan  in  the  clinical  treatment  of  syphili- 
in  human  beings,  has  reported  very  clearly  concerning  the  action  of 
salvarsan  in  the  early  stages  of  these  diseases.  Nobody  expected  to 
get  any  good  results  in  advanced  types  of  these  conditions,  and  if 
such  cases  have  been  treated  at  all,  it  was  usually  at  the  urgent  re- 
quests of  patients  or  their  families.     Experience  has  demonstrated 


324  ACQUIRED    SYPHILIS. 

that  such  cases  may  become  acutely  worse  after  injections  of  sal- 
varsan.  All  experienced  observers  agree  upon  this  point.  It  has 
not  even  been  definitely  settled  whether  undoubtedly  good  effects 
have  been  obtained  in  the  early  stages  of  these  diseases,  in  the 
sense  of  a  specific  action  upon  their  lesions.  Whenever  a  diagnosis 
of  progressive  paralysis  is  made,  and  when  it  is  found  that  anti- 
syphilitic  treatment  produces  remarkable  and  durable  improvement, 
there  are  always  some  doubts  as  to  the  correctness  of  the  diagnosis. 
It  would  be  justifiable  to  regard  such  improvement  after  salvarsan 
as  conclusive  evidence  only  if  a  large  number  of  cases  of  paralysis 
were  arrested  for  a  long  period  or  were  improved  to  a  marked  degree. 
Such  reports  are  still  lacking. 

The  value  of  salvarsan  seems  to  be  somewhat  more  pronounced  in 
locomotor  ataxia.  It  is  true,  pupils  insensible  to  light  remain  in- 
sensible and  lost  patellar  reflexes  do  not  reappear,  though  the  pains 
may  be  lessened.  But  all  the  symptoms  which  are  subject  to  wide 
spontaneous  fluctuations  often  show  a  remarkable  improvement,  fre- 
quently after  a  transient  turn  to  the  worse,  or,  these  symptoms  do 
not  recur  for  a  considerable  length  of  time.  On  this  point  the  obser- 
vations of  almost  all  authors  appear  to  be  identical.  In  addition, 
according  to  Alt,  the  treatment  changes  the  positive  Wassermann 
reaction  in  these  cases  into  a  negative  one,  and  the  reaction  remains 
negative  for  a  number  of  months,  up  to  a  year  and  a  half,  possibly 
for  a  longer  time.  For  these  reasons,  the  injections  of  one  dose  of 
salvarsan  is  at  least  permissible  in  cases  of  tabes  dorsalis  and 
paralysis  in  their  early  stages. 

The  action  of  salvarsan  sets  in. very  rapidly  in  almost  all  cases. 
In  the  lesions  which  are  rich  in  spirochaetae  and  occur  in  the  early 
stages,  these  organisms  are  first  affected.  They  lose  their  mobility, 
assume  bizarre  shapes,  and  disappear  entirely.  This  process  takes 
from  24  to  48  hours  after  an  injection,  but  may  last  longer,  depend- 
ing chiefly  upon  the  anatomic  and  pathologic  conditions  present. 
The  action  of  salvarsan  must  needs  rest  primarily  upon  its  bac- 
tericidal specificaction.  The  rapidity  of  its  action,  the  importance 
of  giving  the  right  dose,  the  Herxheimer  reaction,  the  successful 


THE    SALVARSAN    TREATMENT    OF    SYPHILIS. 


O^D 


influence  upon  other  diseases  caused  by  spirilla  in  man.  Recur- 
rent fever,  framboesia,  Vincent's  angina,  and  in  animals:  Spirillosis 
in  hens  and  geese — all  these  speak  so  eloquently,  that  not  the 
slightest  doubt  can  be  raised  now  regarding  the  specific  action  of 
salvarsan  upon  the  spirochaetae. 

Before  the  onset  of  improvement  is  noted  after  an  injection  of 
salvarsan,  one  often  sees  a  so-called  Herxheimer's  reaction  in  the 
lesions.  Usually  this  phenomenon  appears  sharply  only  in  macular 
or  maculo-papular  eruptions.  The  eruption  becomes  more  dis- 
tinct, larger,  and  many  new  macules  or  maculo-papules  appear. 
Similar  focal  reaction,  or  phenomena  which  can  be  interpreted  as 
such,  have  been  also  noted  in  sclerotic,  mucus,  or  osseous  lesions 
of  the  early  stage,  and  even  in  the  tertiary  stage.  The  general 
impression  is  that  this  Herxheimer's  reaction  is  more  frequently 
and  more  intensely  noted  after  the  use  of  salvarsan  than  after  the 
use  of  mercury.  The  simplest  and  most  plausible  explanation  for 
it  is  found  in  the  theory  that  the  infective  agent  is  rapidly  de- 
stroyed, and  that  in  consequence  there  is  an  increase  in  the  inten- 
sity of  the  local  lesions.  Many  authors  regarded  this  phenomena 
as  an  unfavorable  sign,  an  expression  of  an  irritation  of  the  spiro- 
chgetae  due- to  a  too  small  dose.  Later  experience  has  show^n,  how- 
ever, that  this  assumption  was  quite  unfounded. 

Ulcerating  lesions  become  clean  and  covered  over  with  epithelia 
so  quickly  that  some  observers  have  asserted  that  salvarsan  possesses 
not  only  spirillotropic  properties  but  also  promotes  the  growth  of 
epithelial  tissues.  This  may  be  so,  but  of  course,  is  very  difficult 
to  prove. 

The  improvement  in  the  lesions  is  accompanied  in  very  many 
cases  by  a  marked  increase  in  weight,  and  an  improvement  in  the 
general  w^ell-being.  This  is  clinically  of  great  value,  for  under  ener- 
getic mercurial  treatment  there  is  usually  some  loss  of  weight  to- 
wards the  end  of  the  treatment,  as  well  as  in  impairment  of  the 
general  health.  The  probability  is  that  the  arsenic  in  salvarsan 
has  something  to  do  with  the  improvement  noted. 

Considering  the  question  of  the  formation  of  antibodies,  Taege,- 


326  ACQUIRED    SYPHILIS. 

Duhot,  Scholtz,  Meriowski,  Grouven,  and  others,  have  noted  that 
when  a  mother  is  treated  with  salvarsan,  the  hereditary  syphilis  of 
her  infant  can  be  favorably  influenced.  The  authors  quoted  be- 
lieve that  this  action  is  due  to  the  formation  of  antigens  through  the 
massive  destruction  of  spirochaetae  in  the  mother's  body,  and  that 
the  antigens  are  transferred  to  the  child  with  the  milk.  In  some 
of  these  cases  arsenic  was  found  in  the  mother's  milk,  in  others,  it 
was  not  found.  Treatment  through  the  mother's  milk  is  not  suffi- 
cient, and  that,  moreover,  similar  phenomena  have  been  long  since 
seen  with  mercurial  treatment. 

THE    PERMANENCY    OF    THE    EFFECTS.     COMPARISON 

WITH  MERCURY. 

The  effect  of  salvarsan  upon  syphilitic  lesions  is  no  longer  doubted 
by  anyone.  A  single  injection  of  0.5-0.6  as  a  rule  removes  all  the 
clinical  syphilitic  manifestations.  This  is  probably  most  surely  at- 
tained with  the  alkaline  solution.  The  intravenous  injection  must 
generally  be  repeated  a  second  time  within  ten  or  fourteen  days, 
in  order  to  influence  all  the  morbid  foci. 

Symptomatically  speaking,  therefore,  a  single  injection  of  sal- 
varsan is  equivalent  to  a  course  of  treatment  with  mercury  or  with 
mercury  and  the  iodides,  only  salvarsan  in  many  cases  is  more  effi- 
cient in  that  it  removes  the  symptoms  more  rapidly,  but  also  be- 
cause it  heals  lesions  often  in  a  short  time  which  are  not  influenced 
by  prolonged  mercurial  treatment,  but  are  partly  influenced  by  the 
latter,  or  else  recur  in  spite  of  repeated  courses  of  mercury  injec- 
tions. Naturally,  there  are,  among  the  cases  cited  in  support  of 
this,  many  of  which  cannot  stand  critical  examination,  and  in  which 
a  course  of  calomel  injectoins  would  have  produced  the  same  bene- 
ficial effects  as  salvarsan.  This,  however,  only  proves  the  superi- 
ority of  salvarsan,  for  we  cannot  use  calomel  injections  in  all  patients, 
nor  can  we  use  the  chronic  intermittent  treatment  in  all  cases. 

Most  authors  cite,  as  a  proof  of  the  superiority  of  salvarsan,  its 
action  in  malignant  syphilis.  In  this  class  of  cases  is  salvarsan  so 
immeasureably  superior  to  mercury  and  the  iodides  as  in  these 


THE    PERMANENCY    OF    THE    EFFECTS.  327 

types  of  the  disease.  But  it  must  be  remembered  that  atoxyl  also 
produced  remarkable  improvement  and  cure  in  such  cases,  in  spite 
of  the  fact  that  this  remedy  had  an  insufficient  symptomatic  effect 
in  the  ordinary  forms  of  primary  and  secondary  syphilis. 

The  treatment  of  human  syphilis  with  mercury  and  iodide  has  not 
succeeded  in  arresting  the  spread  of  the  germ  throughout  the  system, 
to  change  the  chronic  relapsing  character  of  the  disease,  nor  to  pro- 
tect against  metasyphilitic  affections.  Does  salvarsan  do  more 
than  this,  aside  from  the  fact  that  as  a  purely  sympomatic  remedy  it 
is  equivalent  to  the  action  of  an  energetic  course  of  treatment 
with  mercury  and  in  some  cases  completely  overshadows  the  effects 
of  mercury?  Is  the  use  of  salvarsan  really  a  therapia  sterilisans 
magna}  Or  at  least  is  salvarsan  able  more  frequently  to  prevent 
the  generalization  of  the  disease,  to  prevent  relapses  and  after-dis- 
ease ?     No  difinite  answer  can  as  yet  be  given  to  these  questions. 

Does  salvarsan  abort  syphilis?  The  literature  is  very  meagre 
on  this  point.  The  success  of  the  treatment  in  such  cases  indicated 
by  the  absence  of  local  and  constitutional  symptoms,  generalized 
glandular  swellings,  and  lesions  of  the  skin  and  mucous  membranes, 
together  with  a  negative  Wassermann  reaction.  Naturally  the 
patients  must  be  observed  and  their  serum  tested  for  months,  and 
even  then  it  is  doubtful  whether  a  permanent  cure  has  been  effected. 
Wechselmann,  Neisser,  E.  Lesser,  Finger,  and  others  have  reported 
such  cases.  From  the  reports  which  have  thus  far  appeared  it 
seems  clear  that  salvarsan  acts  very  well  in  the  very  early  cases  of 
syphilis.  At  any  rate,  we  must  admit  the  possibility  that  in  these 
cases  the  disease  has  been  successfully  aborted,  by  means  of  -a 
therapia  magna  sterilisans.  An  energetic  salvarsan  treatment  should 
be  inaugurated  in  every  case  in  which  the  disease  has  been  dis- 
covered at  its  earliest  stage.  According  to  Alt  this  is  best  done  by 
giving  an  intravenous  injection  of  salvarsan,  then  following  with  an 
intramuscular  injection,  and  excising  the  chancre  if  situated  so 
that  it  can  be  reached. 

Salvarsan  in  the  Primary  Stage.     Many  cases  of  chancres  with 
regional    glandular   enlargement,    without  generalized  symptoms, 


328  ACQUIRED    SYPHILIS. 

have  been  treated  by  means  of  salvarsan.  It  is  as  yet  impossible 
to  say  whether  a  large  percentage  of  such  cases  rem-ain  free  from 
symptoms  clinically  and  serologically.  One  thing  seems  certain, 
however,  namely,  that  nearly  every  author  with  considerable  experi- 
ence has  seen  recognizable  clincial  symptoms  develop  sooner  or 
later  in  these  cases,  in  spite  of  the  fact  that  the  chancre  and  the 
adenitis  had  disappeared.  These  observations  seem  to  be  of  great 
importance  for  they  show  that  salvarsan  treatvient,  in  the  sense  of  a 
therapia  sterilisans  magna  may  fail,  even  when  the  clinical  conditions 
are  favorable  for  its  success. 

Secondary  and  Tertiary  Stages.  No  one  can  deny  at  this  time 
that  salvarsan  acts  very  favorably  in  the  majority  of  cases  with 
secondary  and  tertiary  lesions.  And  yet  it  must  be  admitted  that 
the  number  of  "failures,"  i.e.,  of  cases  which  remain  entirely  unin- 
fluenced or  only  insufficiently  influenced,  is  far  larger  than  might  be 
expected  from  the  first,  and  from  many  of  the  later  reports.  In 
some  of  these  cases  the  dose  of  salvarsan  might  have  been  too  small, 
in  others  the  absorption  may  have  been  insufficient.  In  a  small 
number  of  cases  we  must  also  admit  the  possible  presence  of  ''arsen- 
fast"  spirochaet£e,  for  some  "failures"  remain  uninfluenced  even  by  a 
second  injection  of  salvarsan  in  larger  dose. 

THE  PERMANENCE  OF  THE  EFFECTS  IN  FAVORABLE 

CASES. 

Even  in  those  cases  of  secondary  and  tertiary  lues  in  which  in- 
jections of  salvarsan  produce  rapid  and  complete  disappearance  of 
the  lesions,  it  is  difficult  to  judge  of  the  permanence  of  the  effects. 
We  know  that  tertiary  cases  treated  with  mercury  remain  free  from 
relapses  even  when  the  Wassermann  reaction  is  positive.  It  is 
not  astonishing,  therefore,  that  the  cure  in  some  cases  of  tertiary 
syphilis  remains  permanent  after  salvarsan  treatment.  On  the 
other  hand,  relapses  are  of  special  importance  in  this  stage  of  the 
disease.  One  or  more  such  cases  are  recorded  in  almost  every  more 
important  report. 

The  chroicn-relapsing  character  of  syphilis  is  particularly  noted 


THE    INFLUENCE    OF    SALVARSAN.  329 

in  the  earlier  stages,  and  especially  the  first  eruptions  which  very 
frequently  recur  even  after  energetic  mercurical  treatment — ac- 
cording to  Bruhn's  in  75  per  cent,  of  cases.  There  is  even  a  regular 
interval  for  the  recurrence  of  these  lesions — usually  2  or  3  months. 
We  know  now  that  after  salvarsan  treatment  there  may  also  be 
recurrences  of  the  early  eruptions.  It  is  a  question  whether  the 
frequency  of  these  recurrences  is  greater  with  mercury  treatment 
than  with  salvarsan.  It  is  remarkable  that  the  number  of  recur- 
rences of  the  early  eruptions  is  greater  in  proportion  to  the  length  of 
observation  to  which  the  various  series  of  cases  have  been  subjected. 

THE  INFLUENCE  OF  SALVARSAN  ON  THE  WASSERMANN 

REACTION. 

Naturally,  the  behavior  of  the  Wassermann  reaction  has  been 
studied  with  special  care  in  the  cases  treated  with  salvarsan.  A 
number  of  striking  facts  have  developed  in  the  course  of  these  in- 
vestigations. In  the  first  place,  it  was  found  that,  like  in  cases 
treated  with  mercury,  the  disappearance  of  clinical  symptoms  and 
the  negative  Wassermann  reaction  do  not  occur  simultaneously. 
The  symptoms  disappear  first,  then  the  serum  reaction  becomes 
negative.  The  only  difference  is  that  in  the  use  of  salvarsan  the 
difference  in  time  between  the  clincal  disappearance  of  symptoms 
and_  the  vanishing  of  the  positive  Wassermann  test  is  greater, 
simply  because  the  symptoms  disappear  more  promptly  than  under 
the  use  of  mercury;  while  the  Wassermann  reaction  usually  takes 
about  the  same  length  of  time  to  become  negative. 

Thus  C.  Lange  reports  250  cases  of  syphilis  witu  positive  Was- 
sermann's  in  which  salvarsan  was  used.  Of  these  153  showed 
negative  reactions  within  from  four  to  five  weeks.  In  97  the  reaction 
remained  positive,  and  in  54  the  reaction,  which  was  watched  for  a 
period  of  three  weeks,  did  not  diminish  in  intensity.  These  figures 
correspond  to  those  of  nearly  every  other  author.  The  reaction 
seems  to  remain  positive  for  a  longer  period,  or  even  permanently 
in  tertiary  cases,  just  as  in  patients  treated  with  mercury.  This  is 
especially  the  case  in  patients  who  had  no  treatment  for  many  years 


330  ACQUIRED    SYPHILIS. 

after  infection.  We  may  also  note  here  that,  as  Lange,  Neisser,  ■ 
Stem,  Citron,  and  Blaschko,  and  many  others  have  reported,  a 
reaction  which  had  been  negative  during  the  primary  stage  may  be- 
come positive  sometimes  after  the  injection  of  salvarsan.  Similar 
events  were  noted  also  in  cases  of  secondary  and  tertiary  syphilitic 
affections  where  the  reaction  had  been  negative  before  the  treatment. 
The  most  plausible  explanation  for  this  apparent  pardox  is  that  the 
''positive  phase"  is  accelerated  by  the  sudden  destruction  of  many 
spirochaetse. 

The  diagnostic  value  of  the  Wassermann  reaction  is  firmly  es- 
tablished at  the  present  time.  The  reaction  is  theefore  an  indis- 
pensable part  of  the  control  of  cases  in  which  the  disease  is  supposed 
to  have  been  aborted,  and  which  have  remained  free  from  symp- 
toms— and  also  of  cases  in  which  no  treatment  has  been  used  after 
the  first  two  or  three  years,  but  which  showed  no  symptoms.  On  the 
other  hand,  it  may  be  said  that  the  value  of  the  Wassermann  test  as 
a  criterion  of  an  antisyphilitic  treatment  has  been  exaggerated,  save 
in  cases  in  which  repeated  negative  results  are  obtained  and  in 
which  clinical  symptoms  are  also  absent.  If  we  use  the  Wassermann 
reaction  as  a  criterion  for  each  course  of  treatment,  then  salvarsan  does 
not  present  any  superiority  over  an  energetic  mercury  treatment. 

After  taking  all  the  foregoing  facts  into  consideration,  Tom- 
asczewski  summarizes  his  conclusions  as  follows: 

1.  That  a  single  intramuscular  or  subcutaneous  injection, 
possibly  a  repeated  intravenous  injection,  certainly  a  combined  in- 
travenous and  intramuscular  injection  of  a  sufficient  amount  (0.5 
to  0.6  gm.)  of  salvarsan  produces  marked  symptomatic  effects  in 
cases  of  malignant  syphilis,  often  effects  of  very  long  duration,  and 
not  infrequently  saves  life  in  these  cases. 

2.  That  salvarsan  treatment  attains  the  value  of  an  energetic 
mercurial  course  (calomel  injections)  in  all  other  types  of  syphilis, 
with  relatively  rare  exceptions. 

3.  That  it  is  possible  that  a  permanent  cure  a  therapia  magna 
sterilisans  may  be  effected  early  in  the  primary  stage,  but  that 


THE    INFLUENCE    OF    SALVARSAN.  33 1 

undoubtedly  most  of  these  cases  remain  clinically  and  serologically 
free  from  symptoms  for  a  long  period. 

4.  That  in  cases  of  syphilis  in  any  stage  in  which  mercury  was 
not  tolerated,  or  very  badly  borne,  or  in  which  new  recurrences 
appeared  in  spite  of  repeated  courses  of  mercury,  salvarsan  almost 
invariably  produced  excellent  results — if  not  permanent  cures,  at 
least  cures  lasting  a  long  time. 

5.  That  salvarsan  produces  certain  local  more  or  less  severe 
tissue  changes  in  all  cases  save  when  used  intravenously,  and  that 
it  gives  rise  to  a  series  of  untoward  general  effects,  no  matter  what 
mode  of  administration  be  used.  These  untoward  effects  vary 
greatly  in  character  and  intensity  in  different  individuals.  Unto- 
ward effects  of  serious  nature  have  thus  far  been  noted  in  a  very 
small  proportion  of  cases  after  a  single  injection,  and  in  some  of 
these  cases  they  were  referable  to  faulty  technic  or  some  other 
preventable  cause. 

6.  That  we  must  continue  to  employ  the  chronic  intermittent 
treatment  of  syphilis  and  must  maintain  as  before  the  necessity  for 
a  complete  course  of  treatment  in  deciding  such  quesions  as  trans- 
missibility,  consent  to  marriage,  etc.,  in  every  case. 

7.  That  all  our  experiences  thus  far  (indications,  contra-indica- 
tions,  etc.),  are  essentially  based  upon  single  salvarsan  injections, 
and  that  we  as  yet  know  nothing  of  the  action  and  untoward  effects 
of  a  chronic  intermittent  salvarsan  treatment. 

8.  That  neither  an  injection  nor  an  infusion  of  salvarsan  ex- 
cludes a  simultaneous  or  subsequent  course  of  treatment  with  mer- 
cury and  iodides,  but,  on  the  contrary,  the  special  therapeutic  effect 
of  these  three  remedies  may  be  happily  combined. 

If  the  technic  has  been  perfect,  no  local  reaction  whatever  will 
follow.  Experience  has  shown  that  these  intravenous  injections 
are  well  borne,  and  that  they  may  be  repeated  and  combined  with  in- 
tramuscular injections.  After  the  intravenous  injection  the  patient 
must  at  once  go  to  bed,  where  he  should  remain  about  one  or  two 
days,  inasmuch  as  the  general  reaction  takes  about  that  length  of  time 
to  disappear,  and  proper  rest  materially  aids  the  action  of  most  drugs. 


332  ACQUIRED    SYPHILIS. 

The  general  ontoward  effects  of  salvarsan  depend,  in  the 
first  place,  upon  its  chemical  constitution,  and  partly  also  upon  its 
arsenic  content,  as  well  as  upon  the  dose  injected  and,  finally,  upon 
the  peculiarities  of  individual  patients. 

The  general  reactive  symptoms  which  are  noted  usually  after 
intravenous  injections  of  salvarsan  are  as  follows:  Fever,  nausea, 
vomiting,  diarrhoea.  Rarely  there  is  a  total  absence  of  any  tem- 
perature elevation.  Some  patients  begin  to  feel  chilly  even  during 
the  first  hour  after  the  injections.  Then  the  temperature  rises, 
reading  ioo°  F.  rarely  ioi°  F.  and  over.  Almost  invariably  the 
temperature  then  sinks  to  normal  after  12  hours.  In  all  probability 
these  phenomena  are  due  to  the  intravenous  infusion  as  such,  for 
they  may  be  observed  after  the  use  of  ordinary  normal  salt  solution. 

Nausea,  vomiting,  and  diarrhoea  occur  frequently  and  sometimes 
constipation  is  noted  for  a  few  days.  Sometimes  the  gastric  symptoms 
are  more  pronounced,  sometimes  the  intestinal  arsenic  is  found  in 
the  feces  and  the  vomitus.  These  phenomena  may  be  interpreted 
as  local  effects  of  salvarsan,  and  are  to  some  extent  dependent 
upon  the  size  of  the  dose,  as  Weintraud  points  out. 

In  many  cases  the  patients  complain  of  heavy  sensation  in  the  head, 
headache,  or  vertigo.  Skin  eruptions  are  apparently  rare.  On 
the  other  hand,  the  so-called  herxheimer's  reaction  occurs  with 
marked  intensity.  This  phenomenon,  which  had  been  previously 
noted  by  Welander  and  Jarisch,  consists  is  a  rekindling  of  a  faint 
eruption  which  appears  with  greater  intensity,  or  in  an  unmasking 
of  a  previously  latent  eruption.  The  reaction  is  noted  most  intensely 
in  fresh  exanthems  which  had  not  yet  been  treated,  especially  in 
the  case  of  the  first  generalized  syphilitic  rashes.  The  reaction 
occurs  in  12  to  24  hours  after  an  injection  of  salvarsan.  Similar 
local  reactions  are  noted  in  syphilitic  lesions  in  the  mucous  mem- 
branes or  in  the  internal  organs. 

The  pulse,  which  is  accelerated  during  the  infusion,  and  is  often 
small,  usually  runs  a  parallel  course  with  the  temperature.  Nearly 
all  the  patients  feel  perfectly  well  after  24  or  48  hours. 


SELECTED    FORMULA.  333 

SELECTED  FORMULiE. 
Acute  Urethritis. 

I^.     Sodii  Bicarb.    . 

Sodii  Bromidi aa   oss. 

Tr.  Belladonnae 5 j- 

Aquae  Menthae  Pep. 

Syr.  Acaciae aa   o  iij  • 

M.  Sig. — Tablespoonful  every  3  hours,  to  be  used  as  a  seda- 
tive during  the  first  days  of  gonorrhoea. 

J^.    Caps.  C.  C.  and  S. 

Salolis •.   gr.  X. 

Oleoresinse  Cubebae gr.  v. 

Bals.  Copaibae gr.  x. 

Pepsinae g^-  j- 

M.  Flat  Caps.,  No.  i. 

Sig.- — One  capsule  3  times  a  day  after  meals. 

Chordee. 

I^.     Pulv.  Opii g^"-  ij- 

Camphorae gr-  iv. 

Lupulin gr.  xv. 

01.  Theobrom q.  s. 

No.  I.     Suppository. — Pass  into  the  bowel  at  bedtime. 

Injections  in  Acute  Urethritis. 

I^.     Zinci  Sulph gr.  xv. 

Plumbi  Acetatis gr.  xxx. 

Tr.  Catechu. 

Vin.  Opii aa  f   oi. 

Aq.  Rosae q.  s.  adi  §vj. 

M.  Sig. — Inject  syringeful  night  and  morning. 

I^.     Zinci  Sulph gr.  xvj. 

Plumbi  Acetas f  5  ss. 

Hydrastin(Lloyd's  Colorless). 

Bismuth  Subnit .  .  .aa   oix. 

Tannin  Glycerole. 

Mug.  Acaciae aa   5  ij  • 

Aquae '. c[.  s.  ad  i  qvi. 

M,  Sig. — Shake  well  and  inject  night  and  morning. 


334  SELECTED    FORMULAE. 

JJi.    Plumbi  Acetas gr.  xxx. 

Zinci  Sulph gr.  xv. 

Hydrastin  Sulph gr.  xij. 

Ext.  Ergotse  Fid f   oiv. 

Tr.  Opii f  3iij.  " 

Aquae q.  s.  a<^  f   ovj. 

I^.    Zinci  Chloridi. 

Zinci  lodidi aa  gr.  ij. 

Aquae o viij. 

Sig. — Inject  syringeful  night  and  morning,  during  convalescence. 
{Beljield.) 

Orchitis  and  Gonorrhoea!  Bubo. 

I^.     Ichthyol. 

Ung.  Hydrargyri. 

Ung.  Belladonnae aa   oij- 

Ung.  Petrolei q.  s.  a^  o  j- 

I^.     Guaiacol 5ij- 

Resorcin 3iij. 

Lanolin Si. 

M.  Sig. — Apply  topically  on  guaze. 

I^.    Iodoform. 

Ext.  Belladonnae. 

Ung.  Hydrarg aa  3i- 

Ung.  Zinci  Oxidi q.  s.  ad   oi- 

M.  Sig. — To  be  used  locally. 

Subacute  and  Chronic  Anterior  Urethritis. 

I^.    Zinci  Sulph.  Carb gr.  xx. 

Bismuth  Subnit oi. 

Aquae  Dist §  viij. 

M.  Sig. — Use  freely  as  an  injection  after  each  urination. 

I^.    Zinci  Sulph gr-  x. 

Bismuth  Subnit 3ij. 

Liq.  Hydrastin(colorless) o  ss. 

Aquae q.  s.  o^  Bij. 

Sig. — Inject  3  times  daily. 

I^.    Berberine  Muriate gr.  viij. 

Aquae Oi. 

Sig. — Inject  syringeful  night  and  morning. 


SELECTED    FORMULA.  335 

Finger's  OintMent. 

I^.     Iodine  (crystals) gr-  vi. 

Kalii  lodidi gr.  xxx. 

01.  Amygdalae 5i. 

Lanolin q.  s.   o  i- 

M.  Sig. — Apply  on  bougie  or  by  means  of  an  applicator,  tipped 
with  cotton. 

I^.     Ichthyol gr.  XV. 

Bals.  Peru aa   5iv. 

Resorcin , gr.  xl. 

01.  Recini §iv. 

M.  Sig. — Apply  locally  through  endoscope,  or  use  as  injection. 

Unna's  Ointment. 

]^.    Ag.  NO'* _ gr.  V. 

White  Wax gr.  x. 

Bals.  Peru tt^xxx. 

Cocse  Butter oi- 

Cystitis  (Tubercular). 

Bf.     Iodoform 3ii- 

Liquid  Petrolatum  Sterilized o  vi. 

Sig. — Shake.  Inject  3  ounces  into  the  bladder  and  permit  it  to 
remain.  Each  time  the  patient  urinates  he  should 
stop  the  flow  as  soon  as  oil  appears.  Injections 
should  be  repeated  at  intervals  of  two  or  three 
days. 

Iodoform  Emulsion. 

R.     Iodoform 3vi. 

Gum  Tragacanth gr-  xl. 

Alcohol vtixl. 

Aquge Sviii. 

For  nocturnal  emission,  enuresis,  etc. 

I^.     Tr.  Belladonna Si 

Ext.  Ergotse  Fid Biii- 

Sod.  Bromid .  .  : 3iv. 

Sy.  Zingiberus q.  s.  giii. 

For  nocturnal  emission. 


;^^(r)  SELECTED    FORMULA. 

Aphrodisiac  Pill. 

ly.     Quinnae  Sulph., 

Ferri  Sulph aa  9ij. 

Ext.  Nucis  Vomicae gr.  vi. 

Zinci  Phosphide gr-  ij- 

M.— Flat  Caps.,  No.  xl. 
Sig. — One  caps.,  t.  i.  d. 

Gonorrhoea  in  the  Female. 


> aa    oj. 


I^.     Plunibi  Acet 

Zinci  Sulph 

Aliun  Pulv 

Tannin , 

Aquae O j . 

M. — ^Vaginal  injection. 

Vaginal  Suppository  in  the  Convalescent  Stage 
of  Gonorrhma. 

I^.     Alum.  Pulv \  __ 

Plumbi  Subac.  Cerat / 

Ol.  Theobromae q.  s. 

Ft.  Suppositor}^  No.  12. 

Use  one  night  and  morning. 
I^.     Potass.  Bicarb o j- 

Tr.  Hyoscyam. 

Kavas  Kavse  Ext.  Fid aa   B|. 

Aquae q.  s.  ut.  f t.  f   o  viii. 

M. — Tablespoonful  in  a  wineglassful  of  water,  3  times  daily. 

Lubricant  for  Sounds  and  Bougies. 

{Hyde  and  Montgomery.) 

I^.     Targacanth gr.  xxx. 

Glycerin Sijss.      * 

Ac.  Carbolici n^xx. 

Aq.  Distill q.  s   ad   oiij- 

Phosphaturia. 

I^.     Ac.  Nitric  dil oi- 

Zacch.  Alba o  ss. 

Pepsinae gr.  xxiv. 

Aquae q.  s.  a^^   Biss. 

M.  Sig. — Thirt}'  drops  in  water  with  meals. 


SELECTED    FORMULAE.  337 

F^.     Strychiiicc  Sulph gr-  i- 

Ac.  Arsenosi gr.  i. 

Salolis 3i. 

Pepsinas gr.  xx. 

M. — Flat  Caps.,  No.  xx. 
Sig. — One  Caps.,  t.  i.  d. 

SYPHILIS. 

JF^.     Mass  Hydrarg. 

Ferri  Sulph '. aa  9j. 

Pulv.  Opii gr-  X. 

Quiniae  Sulph 3ij. 

M.— Ft.  pil.  xl. 

Two  pills  3  times  daily  when  patient  is  debilitated. 

I^.     Hydrarg.  lodid.  Vir gr.  v. 

Antim  Ft.  Pot.  Tart gr.  j- 

Pulv.  Opii gr.  V. 

M. — Ft.  pil.  30. 

One  pill  4  times  daily  when  patient  is  robust. 

Hypodermic  Injection  in  Syphilis. 

Gray  Oil  is  an  emulsion  of  metallic  mercury,  made  as  follows: 
Mix  thoroughly  lanolin  with  chloroform,  allow  ch.  to 
evaporate  by  triturating  and  adding  2  parts  to  i  part 
semifluid  lanolin,  i  part  of  the  resulting  salve  added 
to  3  parts  olive  oil  constitutes  gray  oil.  Sterilize  the 
whole. 

I^.     Hydrarg.  Chlor.  Cor gr.  ss. 

Tr.  Ferri  Chlor. . .  • 5ij. 

Liq.  Arsenici  chlor gtt.  xxxvj. 

Acid  Hydrochlor.  Dil : 5j. 

Syr.  Sarsaparillse  Co 


Aqu^ J    ""   ^"J- 

M. — Tablespoonful  in  water  3  times  daily,  to  be  given  when  the 
patient  is  debilifated. 

I^.     Hydrarg.  Chlor.  Cor gr-  iv. 

B  enzoin S  J. 

Cologne  Water Bj. 

Rose  Water q.  s.  ac^   Bvj. 

M. — Use  locally. 
22 


;^;^8  SELECTED    FORMULA. 

Tonics. 

r^.     Acid  Arsen gr-  J- 

Strychnine  Sulph gr.  4- 

Ferri  Sulph 9j. 

Quiniffi  Sulph 3j. 

M. — Ft.  pil.  no.  20. 
One  pill  3  times  daily 

I^.     Ferri  Reduct. 

Quiniae  Sulph 9j. 

Ext.  Nucis  vom ...  - gr-  x. 

Rhei.  Pulv 9i. 

Belladonnae  Ext gr.  iij. 

M. — Liv.  in  pil.  20. 

Sig. — One  after  each  meal. 

Alopecia. 

I^.     Spts.  Ammon,  Aromat f  Bj. 

Glycerinae f  §  ss. 

Tr.  Cantharides f  3 j. 

Aquas  Rosmarin f  B vij. 

M. — ^Apply  to  scalp  morning  and  evening. 

I^.     Ext.  Jaborandi. 

Tr.  Cantharides 1  _      ^ 

^,        .  .  r aa   OSS. 

Glycerim J 

Ung.  Petrolei Biss. 

M. — Apply  locally  with  a  sponge  morning  and  evening. 


Tertiary  Syphilis. 

MIXED    TREATMENT. 

I^.    Hydrarg.  Chlor.  Cor gr.  j- 

Potass.  lodid 5ij- 

Syr.  Ferri  lodid 3iv. 

Syr.  Sarsaparillae  Co 1  .   

.  > aa  f   5uj- 

Aquae J 

M,— Tablespoonful  in  water  3  times  daily. 


SELECTED    FORMULAE. 


}^.  .  Tr.  Ferri  Chlor \ 


aa 


Sss. 


AcidPhos.  Dil / 

S3^r.  Simplex f   oiii- 

M. — A  teaspoonful  3  times  daily. 

I^.     Tinct.  Cantharid f   oiss. 

Tr.  Capsici gtt.  xx. 

Glycerin oi- 

Cologne  Water oi- 

M. — Use  on  the  scalp  at  night. 

Stimulating  Lotions  and  Ointments  to  Apply  to 
Granulating  Surfaces  and  Ulcers. 

I^.     Cerat.  Resin.  Co 5 ]'• 

Balsam  Peruvian 5ij- 

Iodoform 6j- 

Ung.  Petrolei. O  j- 

M. — Use  locally. 

I^,     Ung.Hydrarg.  Nit oj- 

Pulv.  Jalapse 5j- 

Balsam  Peruviani 3j- 

Ung.  Zinci  Oxidi 5j- 

M. — Ft.  ung.     Use  locally. 

Lotions  for  Chancre  and  Chancroid. 


IV. 


I^.     Cupric  Sulph gr. 

Aquae oj- 

M.— Use  locally. 

I^.     Argent.  Nit gr-  ij- 

Aquae  Destil '. 5i- 

M. — Use  locally. 

I^.     Acid  Nitric ^ gtt.  ij 

Aquae O  i- 

M. — Use  locally. 

Red  Wash. 

^.    Zinc.  Sulph gr.x. 

Spin  Rosmarin oiss. 

Tr.  Lavend.  Comp. dij- 

Aquae f  ox. 

M. — Use  locally. 


340  SELECTED    FORMULA. 

Yellow  Wash. 

I^.     Hydrarg.  Chlor.  Cor gr.  j. 

Liquor  Calcis f   oj- 

M. — Use  locally. 

Black  Wash. 

I^.     Hydrarg.  Chlor.  Mite oj- 

Liquor  Calcis f   oiv. 

M. — Bottle  to  be  well  shaken  before  using. 

1^ .     Tannin gi"-  iij  ■ 

Ex.  Opii gr-  ij- 

Cupric  Sulph gr.  |^. 

M. — LTse  locally. 

I^.     Calomel OJ- 

Bismuth  Subnit oij. 

Pulv.  Talcii o j- 

I^.     Ac.  Salicylic gr.  xv. 

Hydrarg.  Chlor.  Mite oij- 

Bals.  Peru oj- 

Tr.  Benzoin , gr.  xxx. 

Ung.  Zinci  Oxidi O j- 

Sig. — Useful  for  stimulating  indolent  venereal  sores. 

1^.     Ac.  Phenici gr-  iv. 

Zinc.  Sulph., 

Pulv.  Alum aa  gr.  xij. 

Aquae q.  s.  oiv. 

Or 

Cupric  Sulphate gr.  iv. 

To  Aquse , o  j- 

I^.     Calomel oj- 

Balsam  Peru o  J- 

Ung.  Zinci.  Oxidi oj- 

Gargles. 

I^.     Acid  Tannici oij- 

Spir.  Vin.  Rect 5 j- 

Mistura  Camphoree f  ox. 

M.— Gargle. 


SELECTED    FORMULA.  34 1 

I^.     Potass.  Chlor 3i^- 

Tr.  Ferri  Chlor 5iij- 

Listerin f   §  iv. 

M.— Pour  half  anounce  in  half  a  glass  of  water,  and  use  as  a 
gargle. 

1^.     Potass.  Chlor 5ij- 

Listerin Sj. 

Ol.  Gaultheriae gtt.  vj. 

Syr.  Sirnplex 5 j. 

Aquae  Distil Bij. 

M. — Gargle. 

Mouth  Washes  for  Mucous  Patches. 

I^.     Acid  Pyrolig oj. 

Aquae oviij. 

M. — Wash  mouth  every  4  hours. 

J^.     Tinct.  Myrrh oi- 

Potass.  Chlor 5iij- 

Aquae 5  iv. 

M. — Wash  mouth  every  three  or  four  hours. 

I^.     Ac.  Tannici Sj- 

Potass.  Ch'or oij- 

01.  Gaultheriae gtt.  vj. 

Aquae O  vj. 

List  of  Genito -Urinary  Instruments  Sequired  for  Office  Use. 

(From  Morton  and  modified  by  the  author.) 

Valentine  irrigator. 

Keyes-Ultzman  syringe. 

Several  glass  hand  syringes.     Capacity  4  to  6  drams. 

Oberlander  or  KoUmann's  dilator  (anteror-posterior). 

Otis's  urethronaeter. 

Bougies  a  boule,  metal,  16  to  32,  omitting  every  other  number. 

Sounds,  steel,  Van  Buren  curve,  16  to  34  F.,  every  other  number. 

Beneque  sounds,  16  to  34F.,  every  other  number. 

Gouley  tunnelled,  silver  catheter,  English  with  stylet,  10,  12,  14  and  16  F. 

Thompson  stone  earcher. 

Flexible  bougies,  smallest  to  26  F.  (alternate  numbers). 

One  dozen  whalebone  guides  or  filiforms. 

Cystoscope  and  ureteral  catheters. 


342                                          SELECTED    FORMULAE.  ; 

Anterior  and  posterior  urethroscope — calibre  24  to  28  F.  j 

Sterilizer.  \ 

Hypodermic  syringe,  with  an  extra  needle  especially  adapted  for  intra-muscular      j 

mercurial  injections. 

Psychrophore,  Jacques  or  ' 

f  Nekton, 

1 

OP,,            1                      Soft  rubber,  ; 

Soft  rubber  catheters        ^  -n^      .  i 

I  Mercier,  i 

[  Coude  and  bi-coude  i 

Irrigating  bottle  (graduated).     16  ounces.  ' 

Three  conical  urine  glasses  and  one  (i)  8  oz.  glass  graduate.  ; 

Alicroscopic  outfit.  ■ 
Alligator  urethral  forceps  for  foreign  bodies  in  the  urethra. 

Laryngeal  lamp  and  head  mirror.  ; 

Tongue  depressor.  i 

Half  dozen  wire  applicators  (flexible)  10  to  12  -in.  in  length  with  the  end  milled.       ; 

Small  magifying  glass.  i 

Pocket  surgical  test.  ] 

Several  white  Jjasins.  i 

Urinalysis  set.                                                                              •  -. 

Vaginal  speculum.  1 
Prostatic  cooler  (Kemp's). 

Prostatic  massage  instrument  (Pezzole).  ■ 

100  QUESTIONS.  ^ 

1.  Symptoms  and  treatment  of  acute  anterior  urethritis.  i 

2.  Symptoms  and  treatment  of  acute  posterior  urethritis.  '          \ 

3.  Differential  diagnosis  of  chronic  anterior  and  posterior  urethritis.  ■ 

4.  Complications  of  acute  anterior  urethritis.  ■ 

5.  Complications  of  posterior  urethritis.  ■■ 

6.  Causes  of  chronic  posterior  urethritis.  1 

7.  Symptoms  of  seminal  vesiculitis. 

8.  Symptoms  of  prostatitis.  i 

9.  Treatment  of  chronic  urethritis.  ■ 

10.  Treatment  of  gonorrhoea  in  female.  | 

11.  Complications  of  gonorrhoea  in  female.  j 

12.  What  is  peri-urethral  phlegmon,  cowperitis  and  folliculitis?  i 

13.  DescriVje  Janet's  treatment  of  acute  urethritis.  •       ; 

14.  What  is  a  chancroid,  its  symptoms,  complications  and  treatment?  « 

15.  Give  the  palliative,  abortive  and  operative  treatment  of  bubo. 

16.  What  is  the  period  of  incubation  of  syphilis  and  what  are  its  primaiy,       ; 

secondary  and  tertiary  symptoms? 


lOO    QUESTIONS.                                               343  j 

17.  Whal  are  the  emergencies  of  syphilis?  | 

18.  Give  the  treatment  of  the  primary,  secondary  and  tertiary  stages.  | 

19.  What  is  meant  by  Colles  and  Prof  eta's  laws? 

20.  Symptoms  of  congenital  syphilis  and  treatment.  ; 

21.  Give  the  law  governing  syphilis  and  marriage. 

22.  Differential  diagnosis  between  chancroid,  chancre,  and  herpes.  i 

23.  What  is  a  mucous  patch,  condylomata  and  treatment  of  each?  \ 

24.  How  would  you  treat  venereal  warts? 

25.  Describe  briefly  the  principles  of  the  Wassermann  reaction.  j 

26.  Give  the  classification  of  skin  eruptions  in  secondary  syphilis.  j 

27.  What  is  Dittels  crisis?  \ 

28.  Give  the  methods  of  diagnosing  stone  lodged  in  upper  portion  of  ureter.  ^ 

29.  Give  the  symptoms  and  treatment  of  chronic  pyelitis. 

30.  What  is  surgical  kidney? 

31.  Describe  the  surgical  treatment  of  B right's  disease  (chronic).  ' 

32.  Symptoms  and  treatment  of  rupture  of  the  bladder. 

7,^.  Symptoms  and  treatment  of  stone  in  the  bladder.  \ 

34.  Symptoms  and  treatment  of  papilloma  of  the  bladder.  j 

35.  What  are  the  different  forms  of  cystitis?  I 

36.  Treatment  of  chronic  cystitis  with  alkaUne  urine.  ; 

37.  Treatment  of  tubercular  cystitis. 

38.  Symptoms  of  hypertrophy  of  the  prostate  gland.  ■ 

39.  Describe  the  palliative  treatment. 

40.  Give  the  indications  for  a  perineal,  supra  pubic,  perineal  and  supra  pubic  i 

combined,  and  the  Bottini  operation.  \ 

41.  What  directions  would  you  give  regarding  daily  catheterization?  i 

42.  What  is  orchidectomy  and  what  is  phimosis?                                  ^  ] 

43.  What  is  paraphimosis  and  give  treatment  ?  \ 

44.  How  does  the  character  of  hematuria  assist  in  locating  the  cause  of  hemor-  | 

rhage  ?  ■ 

45.  Describe  continuous catheterism  and  when  is  it  indicated?  1 

46.  What  is  evacuating  catheterism  ?  'i 

47.  Describe  the  operation  of  amputating  the  penis.  ] 

48.  What  incision  would  you  make  for  a  lumbar  nephrectomy?  \ 

49.  What  incision  would  you  make  for  an  abdominal  nephrectomy  ?  | 

50.  What  incision  should  be  made  in  order  to  resect  the  uterer?  I 

51.  What  is  atonic  impotence  and  name  the  different  types  of  impotence?  ] 

52.  "\^Tiat  is  physical  impotence  ?  I 

53.  How  would  treat  frequent  nocturnal  pollutions?  j 

54.  How  would  you  treat  enuresis  ?  j 

55.  What  are  the  different  forms  of  stricture?  ■ 

56.  "What  is  meant  by  a  stricture  of  large  calibre,  of  small  calibre?  ] 


344  100    QUESTIONS. 

57.  How  diagnose  sfricture  of  the  urethra  ? 

58.  What  are  the  symptoms  of  stricture  of  the  membranous  urethra? 

59.  Give  the  different  methods  of  treatment  of  stricture  of  urethra. 

60.  Symptoms  and  treatment  of  extravasation  of  urine. 

61.  Symptoms  causes  and  treatment  of  retention  of  urine. 

62.  Give  indications  for  the  different  methods  of  operating  for  rehef  of  urethral 

strictures. 

63.  How  would  you  sterilize  urethral  instruments,  rubber  and  steel? 

64.  How  would  you  sterilize  cystoscope  and  ureteral  catheters  ? 

65.  What  are  the  causes,  symptoms  and  treatment  of  varicocele? 

66.  Give  classification  of  hydrocele  and  palliative  treatment. 

67.  Describe  treatment  of  congenital  and  infantile  hydrocele. 

68.  Describe  treatment  of  hydrocele  of  the  cord. 

69.  Give  the  differential  diagnosis  of  hydrocele,  chronic  orchitis,   varicocele, 

and  hernia. 

70.  Symptoms  of  suppression  of  urine. 

71.  Symptoms  and  causes  of  uremia. 

72.  Symptoms  and  forms  of  urethral  fever. 

73.  Give  the  differential  diagnosis  between  uremia,  retention  and  suppression 

of  urine. 

74.  Causes  of  undescended  tesicle;  treatment. 

75.  Give  the  methods  of  determining  the  functional  activity  of  a  supposed 

diseased  kidney. 

76.  How  prepare  a  patient  for  a  suprapubic  cystotomy? 

77.  Causes,  symptoms  and  treatment  of  movable  kidney. 

78.  Give  the  symptoms,  diagnosis  and  treatment  of  stone  in  the  kidney. 

79.  What  are  the  various  operations  performed  on  the  kidney? 

80.  Describe  the  Van  Hook's  operation. 

81.  What  is  epispadias,  hypospadias? 

82.  What  is  exstrophy  of  the  bladder? 

83.  W^hat  are  the  varieties  of  initial  lesion? 

84.  What  are  the  indications  for  retrograde  catheterization? 

85.  Describe  the  technic  and  uses  of  the  cytoscope. 

86.  Describe  the  technic  and  uses  of  the  endoscope. 

87.  Describe  Doyen's  operation. 

88.  How  would  you  treat  tubercular  epididymitis  ? 

89.  Give  the  different  methods  of  treatment  in  secondary  syphilis. 

90.  Give  differential  diagnosis  of  gonorrhoeal  and  simple  rheumatism.     Describe 

the  course  by  which  infection  is  conveyed  from  (a)  the  epididymis  to  the 
prostate,  (&)  from  the  seminal  vesicles  to  the  testicle,  from  urethra  to  the 
kidney. 

91.  Describe  briefly  the  anatomy  and  physiology  of  the  urethra. 


100    QUESTIONS.  345 

92.  How  is  fluid  in  the  scrotum  prevented  from  extravasating  into  the  abdomen  ? 

93.  Describe  the  two  glass  urine  test,  and  what  knowledge  is  obtained  by  it? 

94.  Name  the  causes  of  sterility. 

95.  What  is  meant  by  cryoscopy?     Give  the  principles  of  its  applications  and 

state  its  uses. 

96.  What  are  the  advantages  of  hypodermic  medication  in  syphilis? 

97.  Describe  briefly  the  Salvarsan  treatment  of  syphilis. 

98.  Describe  the  treatment  of  tuberculous  cystitis. 

99.  What  are  the  usual  complications  of  stricture  and  hypertrophied  prostate 

of  long  standing  ? 

100.  What  is  meant  by  segregation  of  the  urine — and  how  is  it  accomplished? 


INDEX 


Abnormal  constituents  of  urine,  6 
Abortive  treatment  of  bubo,  234 

treatment  of  urethritis,  25 
Abscess  of  Cowper's  gland,  77 

periurethral,  76 

of  prostate,  154 

of  Littre's  glands,  76 
Acquired  hydrocele,  140 

phimosis,  64 

stricture,  87 

syphilis,  244 
Adenitis,  syphilitic,  255 
Adenoma  of  bladder,  204 
Adenopathy  of  syphilis,  255 
Albumin  in  urine,  7 
Alkaline  phosphates  in  urine,  6 
Alopecia,  syphilitic,  266,  267 
Ammoniacal  odor  of  urine,  2 
Amputation  of  penis,  complete,  73 

partial,  73 
Anastamosis  of  vas  deferens,  123 
Aneurism  in  syphilis,  283 
Anterior  urethritis,  acute,  23 
Anus,  syphilis  of,  279 
Aponeurosis,  syphilis  of,  280 
Argyll- Robertson  pupil,  284 
Argyrol  in  urethritis,  29 
Arthritis,  gonorrhceal,  36 

use  of  bacterins  in,  39,  40 

serum  therapy,  39 

mixed  bacterins,  40 
Aspirator,  Hayden's,  142 
Astringents,  use  of,  in  urethritis,  28 
Ataxia,  locomotor,  284 
Atonic  impotence,  126 

seminal  vesiculitis,  135 
Atropia  in  enuresis,  119 
Atrophy  of  testes,  146    • 
Average  composition  of  urine,  4 
Ayre's  cystoscope,  225 
Aspermia,  122 
Azoosperma,  122 


Bacillus-coli-communis,  13 
Bacillus  of  Ducrey  and  Unna,  230 
Bacillus  ;smegma,  13 
Bacteriology  of  chancroid,  230 

of  syphilis,  239 
Bacteriuria,  119 
Balanitis,  41,  71,  231 
Balano-posthitis,  41,  71 
Bartholinitis,  gonorrhceal,  59 
Belfield's  operation,  133 
Beneque-bougie,  94,  159 
Bi-coude  catheter,  165 
Bigelow's  evacuator,  202 

lithotrite,  201 
Bile  in  the  urine,  9 

Gmelin's  test  for,  9 

Heller's  test  for,  9 
Bladder,  cysts  of,  204 

exstrophy  of,  206 

fibroma  of,  204 

foreign  bodies  in,  207 

myxoma  of,  204 

papillomata  of,  204 

fulguration  treatment  of,  205 

rupture  of,  206 

tapping  of,  113 

traumatisms  of,  206 

tuberculosis  of,  208 

tumors  of,  204 
benign,  204 
diagnosis  of,  205 
malignant,  204 
symptoms,  204 
Blood  in  the  urine,  10 

changes  of,  in  syphilis,  244 
in  semen,  125 
Blood-vessels,  syphilis  of,  283 
Bones,  syphilis  of,  280 
Bottini's  galvano-cautery,  171 

operation,  170 
Bougies,  a  Boule,  95 

Beneque,  94,  159 


347 


>aS 


INDEX. 


filiform,  95 

flexible,  94 

introduction  of,  98 

olivary,  94 

uses  of,  94 

Van  Buren's,  93 
Bronchi,  syphilis  of,  279 
Bubo,  chancroidal,  233 

gonorrhoea! ,  39 

indolent,  233 

syphiHtic,  255 
Buerger's  cysto  urethroscope,  221 
Bullous  syphilides,  274 
Bursas,  syphilis  of,  280 

Calculi,  calcium  oxalate,  199 

in  kidney,  181 

mulberry,  16,  199 

phosphatic,  211,  16,  199 

uric  acid,  15,  199 

uratic,  199 

vesical,  15,  199 
Carcinoma  of  penis,  72 
diagnosis,  73 
etiology,  72 
treatment,  73 

of  prostate,  175 

of  testes,  148 
Castration,  149 
Casts  in  the  urine,  1 1 
Cathelin's  urine  segregator,  228 
Catheterization  of  ureters,  224 

retrograde,  in 
Catheter  life,  166 
Catheters,  bi-coude,  165 

Coude,  165 

Mercier,  174 

Nelaton,  174 
Cavernitis,  79 
Cerebral  syphilis,  283 
epilepsy  in,  285 

tumors,  syphilitic,  284 
Chancre,  247 

complications,  251 

diagnosis,  249 

from  chancroid,  233 
epithelioma,  248 

duration,  248 

extragenital,  247 

of  finger,  252 

follicular,  249 

genital,  247 


Chancre,  herpetiform,  250 

Hunterian,  249 

induration  of,  248 

papular,  249 

silver  spot,  249 

site,  247 

synonyms,  247 

of  tongue,  251 

of  tonsil,  251 

termination  of,  251 

treatment,  252 

umbilicated,  249 

of  urethra,  250 

varieties,  249 
Chancroid,  bacteriology  of,  230 

complications,  231 

definition,  230 

diagnosis,  231 

from  balanitis,  233 
chancre,  233 
eczema,  233 
herpes,  233 

duration,  231 

mode  of  infection,  230 

period  of  incubation,  231 

phagedenic,  237 

site,  231 

source  of  origin,  230 

treatment,  235 
varieties  of,  231 
Chancroidal  bubo,  233 
diagnosis,  234 
treatment,  234 

paraphimosis,  237 
Chlorides  in  urine,  4 
Choroid,  syphilis  of,  271 
Circumcision,  64 
Civiale's  urethrotome,  loi 
Cock's  operation,  109 
CoUe's  law,  287 
Color  of  urine,  3 
Composition  of  urine,  4 
Condylomata,  261,  279 
Congenital  hydrocele,  140 

diagnosis,  141 

treatment,  141 
Congenital  phimosis,  64 

stricture,  88 
Congestion  of  prostate,  54 
Congestive  stricture,  87 
Continuous  dilatation  of  stricture,  103 
Contusions  of  scrotum,  139 


INDEX. 


349 


Copaiba  in  urine,  8 
Coryza  in  syphilis,  288 

treatment,  291 
Coude  catheter,  165 
Cowperitis,  acute,  36,  77 

chronic,  77 

suppurative,  77 

treatment  of,  77 
Cowper's  gland,  abscess  of,  77 
Cry  OS  copy,  213 
Crypts  of  Morgagni,  76 

inflammation  of,  76 
Curvature  of  penis,  79 
Cystitis,  194 

etiology,  194 

gonorrhoeal,  44 
diagnosis,  45 
treatment,  45 

pathology  of,  195 

prognosis,  196 

septic,  194 

symptoms,  196 

treatment,  197 

urinary  signs,  195 

varieties,  194 
Cystoscope,  use  of,  in  prostatic  hyper- 
trophy, 165 
Cystoscopic  views,  220 
Cystoscopy,  219 
Cystotomy,  suprapubic,  203 
Cysto  urethroscope,  222 
Cysts  of  the  bladder,  204 

of  the  kidney,  184 

of  the  scrotum,  139 
Czerny's  incision,  190 

Dactylitis,  syphilitic,  281,  282 
D'Arsenval  current,  use  of  the,  173 
Decapsulation,  renal,  192 
Dermatoses  of  scrotum,  139 
Dessication  of   papillomata    (see  ful- 

guration) 
Diazo-reaction,  Ehrlich's,  14 
Differential  diagnosis  of  simple  and 
gonorrhoeal  arthritis,  38 
of  chancre  and  chancroid,  232 
Dilatation  of  stricture,  103 
Dilatation,  untoward  effects  of,  96 
Dilating  urethrotome  (Otis),   loi,  106 
Dilator,  Gross,  105 

use  of,  105 

Thompson's,  104 


Ditel's  crisis,  185 

Divulsion  in  stricture,  1 1 1 

Dorsal  incision  of  paraphimosis,  69 

Doyen's  operation,  143 

Drugs  causing  eruptions,  257 

Ducrey  bacillus,  230 

Dyspnoea,  syphilitic,  279 

Ears,  syphilis  of,  272 
Ecthyma,  syphilitic,  262 
Ehrlich's  Diazo  reaction,  14 
Electrolysis  of  stricture,  in 
Elephantiasis  of  penis,  78 

of  scrotum,  139 
Emissions  nocturnal,  125 
Encysted  hydrocele,  144 
Endometritis,  gonorrhoeal,  59 
Endoscope,  use  of,  213 
Enuresis,  117 
Epididymis,  anatomy  of,  138 

hydrocele  of,  144 

inflammation  of,  144 
diagnosis,  144 
treatment,  144 

strangulation  of,  145 

syphilis  of,  281 
Epididymitis,  49 
Epididymo-orchitis,  50 
Epididymotomy,  52 
Epidural  injections,  119 
Epilepsy  in  cerebral  syphilis,  285 
Epispadias,  74 

treatment,  75 
Epithelia  in  urine,  12 
Eruptions,  caused  by  drugs,  258 

of  syphilis,  256,  257,  259 
Esbach's  quantitative  test,  8 
Examination  of  urine,  i 

general  technic,  i 

■reaction,  tests  for,  2 
Exploration  of   the  urethra  in   stric- 
ture, 94 
Extrophy  of  bladder,  206 
External  urethrotomy,  107 

without  a  guide,  107,  108,  109 
Extirpation  of  penis,  complete,  73 

Fat  in  the  urine,  (see  lipuria) 
Fehling's  test  for  sugar  in  urine,  8 
Filiform  bougie,  95 
Finger's  ointment,  formula  of,  335 
use,  48 


350 


INDEX. 


Fingers,  syphilis  of,  281,  282 
Flexible  bougie,  94 
Floating  kidney,  184 
Follicular  urethritis,  46 
Foreign  bodies  in  the  bladder,  207 

urethra,  85 
Fowler's  test,  5 
Formula  for  acute  urethritis,  333 

for  aphrodisiac,  336 

for  bubo,  334 

for  chancres  and  chancroids,  339 

for  chordee,  ;^^^ 

for  cystitis,  335 

of  Finger's  ointment,  335 

for  gargles,  340 

for  gonorrhoea  in  female,  336 

of  iodoform  emulsion,  335 

of  lotio  nigre,  340 

of  lubricant,  336 

of  mouth  washes,  341 

for  orchitis,  334 

for  phosphaturia,  336 

of  red  wash,  339 
Formula  for  syphilis,  337,    338,  339 

for  tubercular  cystitis,  335 

of  Unna's  ointment,  335 

of  yellow  wash,  340 
Fracture  of  penis,  79 
Freyer's  operation,  169 
Fulguration  of  papillomata,  205 

Galvano-cautery,  Bottini's,  171 
Gangrene  of  penis,  78 

of  scrotum,  139 
Glands  of  Littre,  76 
Glycosuria,  8 
Gmelin's  test,  9 
Gonococci  in  the  urine,  13 
Gonococcus  in  urethritis,  20 

distinguishing  features  of,  20 
.    inoculation  of,  22 

technic  for  examination  of,  20 
by  Gram's  method,  21 
by  Von  Wahl's  method,  22 
toxins  from,  22 
Gonorrhoea,  in  the  female,  57 
diagnosis,  58 
symptoms,  58 
treatment,  60 
of  mouth,  55 
of  rectum,  55 
diagnosis,  55 


Gononlicca  of  rectum,  prognosis,  55 
symptoms,  55 
treatment,  55 
Gonorrhoeal  arthritis,  36 
barthoUnitis,  59 

treatment  of,  63 
endometritis,  59 
ophthalmia,  33 
diagnosis,  34 
prognosis,  34 
symptoms,  33 
treatment,  34 
rheumatism,  36 
vaginitis,  59 
vulvitis,  59 
Goule's  beaked  bistoury,  107 
Gradual  dilatation  of  stricture,  103 
Gross  dilator,  105 
Gumma ta  of  pharynx,  278 

of  soft  palate,  278 
Gummatous  lesions,  277 
of  palate,  278 
of  pharynx,  278 
syphilides,  274 
ulcerative,  275 
treatment,  275 
Guyon's  syringe,  47 

Haematocele,  of  epididymis,  145 

spermatic  cord,  145 

testis,  145 

tunica  vaginalis,  145 
Haematuria,  120 

treatment,  121 
Hagner's  operation,  52 
Hayden's  aspirator  and  trocar,  142 
Heat- test  for  albumin,  7 
Heller's  test,  9 
Hemataspermia,  125 
Hemorrhage  from  urethra,  121 

causes,  121 

treatment,  122 
Hereditary  syphilis,  285 

prognosis  of,  288 

prophylaxis  of,  291 

symptoms  of,  285 

treatment,  289 
Herpes,  progenitalis,  71 

causes,  71 

diagnosis,  72 

treatment,  72 
High  operation  for  varicocele,  152 


INDEX. 


351 


Hoarseness  in  syphilis,  278 
Horwitz's  operation,  109 
Hutchinson's  teeth,  288 
Hydrocele,  acquired,  140 

diagnosis,  141 

etiology,  142 

treatment,  141,  142 
Hydrocele,  congenital,  142 

encysted,  142 

of  spermatic  cord,  144 
diffused,  144 
encysted,  144 
Hydronephrosis,  180 

diagnosis,  181 

prognosis,  181 

symptoms,  180 

treatment,  181 
Hypertrophy  of  prostate,  160 

Freyer's  operation  for,  169 

uses  of  cystoscope  in,  165 
Hypospadias,  74 

treatment,  74 

Impotence,  atonic,  126 

causes,  126 

organic,  130 

prognosis,  126 

psychical,  129 

sexual,  126 

symptomatic,  129 

symptoms,  126 

treatment,    constitutional,   127 

local,  124 
Incontinence  of  urine,  nocturnal,  117 
Indican  in  the  urine,  6 
Indigo  Carmin  test,  228 
Indolent  bubo,  233 

Infectiousness  of  chronic  urethritis,  23 
Infective  balano  posthitis,  250 
Inflammation  of  ureter,  211 
Inflammatory  stricture,  87 
Injections  in  urethritis,  28 
Internal  urethrotomy,  104 
Inunctions,  mercurial,  290 

contraindications  to,  290,  298 
lodism,  304 
Iritis,  syphilitic,  270 

treatment,  270 
Irrigations  in  urethritis,  29 

potassium  permanganate,  30 

Janet's  method,  30 
Juxta-urethral  sinuses,  75 


Ivemp's  prostatic  cooler,  154 
Kidney,  calculi  in,  t8i 

cysts  of,  184 

floating,  184 

how  to  palpate,  185 

lavage  of,  227 

movable,  184 

Ditel's  crisis  in,  185 

stone  in,  190 

surgical  anatomy,  178 

suppurative  affections  of,  186 

tuberculosis  of,  189 

tumors  of,  183 
symptoms,  184 
treatment,  184 

traumatisms  of,  186 
Keyes-Ultzman  syringe,  44 
Koenig's  incision,  190 
Kolischer's  method,  224 
Kollmann  dilator,  48 

Langenbuch's  incision,  190 
Lavage  of  kidneys,  227 
Law,  CoUe's,  287 

Profeta's,  287 
Lipuria,  14 
List  of  genito-urinar}^  instruments,  341 

of  hundred  questions,  342 
Lithiasis  of   urinary  tract,   Roentgen 

diagnosis  of,  217 
Litholapaxy,  200 

contraindications  to,  201 

indications  for,  200,  201 

technic,  201 
Lithotomy,  perineal,  202 
Littre's  glands,  abscess  of,  76 

function  of,  83 
Locomotor  ataxia,  284 
Lymphangitis  in  urethritis,  41 

of  penis,  78 

Maisonneuve  urethrotome,  99 

use  of,  99 
Malignant  syphiUtis,  285 
Martin's  operation,  123 
Mercier  catheter,  174 
Mercurial  fumigations,  299 

salivation,  304 
Methylene  blue  to  test  renal  function, 

228 
Mixed  infection,  250 

treatment,  297 


352 


INDEX. 


Modified  rapid  dilatation,  104 

Morning  drop,  46 

Morgagni,   sinuses   of    (see   crypts   of 

Morgagni) 
Mouth,  gonorrhoea  of,  55 
Movable  kidney,  184 

diagnosis,  185 

etiology,  184 

prognosis,  185 

symptoms,  185 

treatment,  185 
Mucous  patches,  syphilitic,  263,  264 
Mucus,  presence  of,  in  urine,  9 
Mulberry  calculus,  199 
Muscles,  syphilis  of,  279 
Myositis,  syphilitic,  279 

Neapolitan  ointment,  290 
Nelaton  catheter,  174 
Nephrectomy,  191 
Nephrolithotomy,  191 
Nephropex}'-,  192 
Nephrorrhaphy,  192 
Nephrotomy,  190 
Neuralgia  of  the  penis,  78 
Nitric  acid  test,  7 
Nocturnal  emissions,  125 
treatment,  125 
incontinence  of  urine,  117 
Noguchi's  test,  311,  312 

Obermeyer's  test,  6 

Odor  of  urine,  3 

(Edema  of  scrotum,  139 

Oligozoospermia,  123 

Olivary  bougie,  94 

Onychia,  267 

Open  operation  for  varicocele,  151 

Ophthalmia,  gonorrhoeal,  33 

Orchidopexy,  150 

Orchitis,  54 

chronic,  54 
causes,  54 
treatment,  54 

syphilitic,  281 
treatment,  283 
Organic  impotence,  130 

stricture,  90 
Osmic  acid  test,  6 
Osteo-periostitis,  syphilitic,  280 
Otis's  dilating  urethrotome,  loi,  106 

urethrometer,  96 
Overflow  of  retention,  164 


Papilloma ta  of  bladder,  204 

of  penis,  72 
Paracystitis,  194 
Paraphimosis,  66  • 

causes,  66 

chancroidal,  237 

treatment,  66 

by  dorsal  incision,  69 
Pederson's  grooved  sound,  loi 
Penis,  carcinoma  of,  72 

complete  extirpation  of,  73 

curvature  of,  79 

elephantiasis  of,  78 

fracture  of,  79 

gangrene  of,  78 

lymphangitis  of,  78 

neuralgia  of,  78 

papillomata  of,  72 

partial  amputation  of,  73 

sarcoma  of,  74 

tumors  of,  78 
Pericystitis,  194 
Perineal  lithotomy,  202 

prostatectoniy,  168 

by  Young's  method,  176 

prostatotomy,  167 
Perinephritis,  178 

symptoms,  178 

treatment,  178 
Perionychia  268 

treatment,  269 
Periurethral  abscess,  76 

infections,  35 
Pederson's  tunnelled  sound,  loi 
Phagedenic  chancroid,  231,  237, 
Phenol  sulphone  phthalein  test,  229 
Phimosis,  64 
Phloridzin  test,  228 
Phlebitis  of  penis,  78 

syphilitic,  283 
Phosphatic  calculi,  179 
Phosphaturia,  5 

test  for,  6 
Posterior  urethra,  rupture  of,  114 

urethritis,  acute,  42 
complications,  43,  47 
diagnosis,  43 
duration,  43 
epididymitis  in,  49 
comphcations,  50 
diagnosis,  51 
etiology,  49 


TNDICX. 


or") 

o5o 


Posterior    urethriLis     cpidicl}'!!!!!!^ 
orchitis  and,  50 
])rognosis,  51 
symptoms,  49 
treatment,  51 
Posthitis,  41,  71 
Postho-balanitis,  41,  71 
causes,  71 
diagnosis,  71 
symptoms,  71 
,  treatment,  71 
Preputial  follicles,  abscess  of,  35 
Priapism,  77,  199 
Probe  gorget,  Teale's,  108 
Prof  eta's  law,  287 
Prostate,  abscess  of,  154 
diagnosis,  155 
treatment,  155 
anatomy  of,  153 
calculi  in,  175 
carcinoma,  175 
symptoms,  175 
treatment,  176 
congestion  of,  54 
diagnosis,  54 
symptoms,  54 
hypertrophy  of,  160 

changes  in  urethra  in,  162 
complications,  164 
diagnosis,  164 
etiology,  160 
pathology,  161 
residual  urine  in,  163 
retention  of  urine  in,  164 

treatment  of,  173 
symptoms,  162 
treatment,  166 
operative,  166 
palliative,  166 
inflammation  of,  153 
malignant  growths  of,  175 
pathology  of,  156 
secretion  of,  in  urine,  12 
tuberculosis  of,  174 
Prostatectomy,  perineal,  168 

suprapubic,  168,  169 
Prostatotomy,  perineal,  167 

urethral,  167 
Prostatic  cooler,  Kemp's,  154 
Prostatitis,  acute,  153 
etiology,  154 
symptoms,  154 

23 


in.       Prostatitis,  treatment,  154 

chronic,  155 

treatment,  159    . 

follicular,  154 

parenchymatous,  154 

pathology  of,  156 
Prostatorrhoea,  142,  156 
Pseudomembranes  in  urine,  12 
Psychical,  impotence,  129 

diagnosis,  129 

prognosis,  129 

symptoms,  129 

treatment,  129 
Psychrophore,  127,  159 
Ptyalism,  304 
Pyelitis,  186 

diagnosis,  188 

patholog)^  187 

symptoms,  187 

treatment,  188 
Pyelonephritis,  186 
Pyonephrosis,  179 
Pyuria,  10 

Question  of  S3rphilis  and  marriage,  292 
Questions,  list  of,  342 

Rapid  dilatation  of  stricture,  103 
Reaction  of  urine,  2 
Rectum,  gonorrhoea  of,  55 
Relapsing  urethritis,  33 
Renal  calculi,  181 

decapsulation,  192 

tuberculosis,  189 
Retarded  syphilis,  305 
Retention  of  urine,  112,  17,  164 

treatment,  173 

in  urethritis,  36 

overflow  of,  164 
Retrograde  catheterization,  in 
Rheumatism,  gonorrhoeal,  36 

complications,  37 

course,  37 

diagnosis,  37 

prognosis,  38 

symptoms,  37 

treatment,  38 
Roentgenogram,  183 
Rupture  of  bladder,  206 

of  urethra,  114 

Salivation,  mercurial,  304 
Salvarsan  action  of,  315 


354 


INDEX. 


Salvarsan,  bladder  disturbances  after 

the  use  of,  320 
Boehm's  apparatus  for  giving,  318 
by  effects  of,  332 
contraindications,  322 
diagnostic  value  of,  330 
dose  of,  315 
effect   of,    on   ulcerating   lesions, 

of  syphilis,  325 
elimination  of,  321 
Herxheimer's   reaction   after   the 

use  of,  324,  325,  332 
influence  of,  on  the  Wassermann 

reaction,  329 
in  aborting  syphilis,  the  question 

of,  327 
in  congenital  syphilis,  323 

locomotor  ataxia,  323 

primary  syphilis,  327 

progressive  paralysis,  323,  324 

secondary  syphilis,  328 

tabes  dorsalis,  323 

tertiary  syphilis,  328 
in  syphilis,  315 

intramuscular  injection  of,  317 
intravenous  injection  of,  318 

Boehm's  apparatus  for  giving, 
321 
Kromeyer's  method  of  using,  316 
Lasser's  neutral  emulsion  of,  317 
Lesser' s  method  of  using,  317 
Mortality  of,  322. 
Neutral  emulsions  of,  316 
oily  suspensions  of,  316 
.   permanency  of  the  effects  of,  in 

comparison  with  mercury,  326 
permanency  of  the  effects  of,  in 

favorable  cases,  326 
Skin  eruptions  following  the  use 

of,  320 
summary  of  conclusions  regarding 

the  value  of,  330 
therapeutic  effects  of,  322 
untoward  effects  of,  332 
Wechselmann's  method  of  giving, 

316 
Sarcoma  of  penis,  74 

of  testes,  148 
Scleritis,  syphilitic,  269 
Sclerosis  of  tongue,  277 
Scrotum,  anatomy  of,  138 
contusions,  139 


Scrotum,  cysts,  139 
dermatoses,  139 
elephantiasis,  139 
gangrene,  139 
oedema,  139 
tumors,  139 
wounds,  139 
Secondary  syphilis,  255 
Sediments,  urinary,  9 
Segregators,  urine,  228 
Cathelin's,  228 
Harris's,  228 
Selected  formulae,  333 
Seminal  vesicles,  secretions  of,  12 
vesiculitis,  131 
acute,  131 

complications,  132 
diagnosis,  132 
symptoms,  132 
treatment,  132 
anatomy  of,  131 
atonic,  135 
chronic,  132 
diagnosis,  136 
duration,  136 
etiology,  136 
symptoms,  136 
treatment,  137 
Septic  cystitis,  194 
Serpiginous  syphilide,  292 
Serum  diagnosis  of  syphilis,  305 
Sexual  impotence,  126 
Simon's  incision,  190 
Simple  cystitis,  194 
Sinus  pocularis,  84 
Sinus,  juxta-urethral,  75 
Skene's  glands,  infection  of,  58 
Skin,  syphilis  of,  256 
Silver  spot  chancre,  249 
Smegma  bacillus,  13,  14 
Sounding    ureters,    Kelley's   method, 

224 
Specific  gravity  of  urine,  4 

urethritis,  19 
Spermatic  cord,  hydrocele  of,  144 

torsion  of,  145 
Spermatocele,  145 
Spermatazoa  12 
Spermatorrhoea,  124 

treatment,  124 
Spirochaeta  pallida,  239 
cultivation  of,  246 


INDEX. 


:55 


Spirochajta  pallida,  dark  ground  illum- 
inator for  examining,  241,  242 
Giemsa's  stain  for,  244 
refringens,  239 
Wright's  stain  for,  244 
Stellwagen's  ether  inhaler,  191 
Sterility,  122 
Stone    in    the    bladder    (see    vesical 

calculus) 
kidney,  181 

diagnosis,  181 

symptoms,  181 
ureter,  211 

diagnosis,  211 

treatment,  212 
Strangulation  of  epididymis,  145 
testes,  145 

treatment,  145 
Stricture,  acquired,  87 

changes  in  the  urine  in,  93 
complications,  93 
congenital,  87 
congestive,  87 

continuous  dilatation  of,  103 
diagnosis,  94 
divulsion  of,  iii 
electrolysis  of,  1 1 1 
examination  for,  96,  97 
exploration  for,  94 
gradual  dilatation  of,  103 
in  anterior  urethra,  93 

treatment,  99 
in  deep  urethra,  102 

treatment,  102 
inflammatory,  87 
of  female  urethra,  86 

treatment,  86 
of  ureter,  211 
organic,  90,  91 

location  of,  91 

pathology,  90 

symptoms,  91 

treatment,  99 
organic,  varieties,  91 
rapid,  dilatation,  103 
seat  of,  88 
spasmodic,  88 

causes,  89 

diagnosis,  89 

treatment,  89 
traumatic,  87 
types  of,  87 


Subcutaneous  ligation    for   varicocele, 

152 
Sugar  in  the  urine,  8 

tests  for,  8 
Superficial  erosion,  249 

ulceration,  249 
Suprapubic  cystotomy,  203,  205 

prostatectomy,  168,  169 
Suppurative     affections      of     kidney, 
186 

cystitis,  205 
Symes  operation,  108 
Symptomatic  impotence,  129 
Synovitis,  syphilitic,  281 
Syphilides,  bullous,  274 

erythematous,  260 

gummatous,  274 

impetigoform,  262 

large  flat  papular,  261 

miliary  papular,  261 

mioist  papular,  261 

papular,  260 

papulo  pustular,  259 
squamous,  259 

periods  of,  259 

pigmentary,  263 

pustular,  262 
crustaceous,  259 

retiform,  263 

rupial,  276 

serpiginous,  276 

tubercular,  262,  274 

varieties  of,  259 
Syphilis,  accompanying  lymphatic  ad- 
enopathy, 255 

acquired,  238,  244 

and  marriage,  292 

blood  changes  in,  244 

by  conception,  287,  292 

cachexia  of,  255 

cerebral,  283 

complications,  256 

definition  of,  238 

eruptions  of,  256 

f    distinguishing  features  of,  257 

etiology,  239 

fever  in,  254 

general  consideration  of,  238 

headaches  in,  255 

hereditary,  239,  285 

immunity  of,  239 

incubation  of^  248 


56 


INDEX. 


Syphilis,  jaundice  in,  255 
lymphocytosis  in,  244 
mahgnant,  285 
meningeal,  284 
modes  of  infection  of,  246 
mucous  patches  in,  263 
neujralgia  in,  255 
of  anus,  279 

blood-vessels,  283 

bones,  272 

bronchi,  279 

ear,  272 

eye,  269,  270,  271 

hair,  267 

larynx,  265,  278 

lungs,  279 

mouth,  264 

mucous  membrane,  263 

nails,  267 

nervous  system,  283 

periosteum,  272 

rectum,  279 

skin,  256 

spinal  cord,  284 

teeth,  288 

tendons  and  sheaths,  280 

tongue,  264,  277 
osteoscopic  pains  in,  255 
phonation  in,  265 
primary,  244,  247 
prognosis,  245 
retarded,  287 
rheumatism  in,  255 
secondary,  254 

of  the  skin,  256 
serum  diagnosis  of,  305 
synonyms,  238 
tertiary,  272 
test  for,  Klausner's,  311 

Noguchi's,  311 

Butyric  acid  method,  313 

Porges  and  Meier's,  311 

Wassermann's,  310 

influence  of  treatment  upon, 
312 
transmisison  of,  287 
treatment  of,  289,  292 

by  inunctions,  290,  298 

contraindications  to,  290 

by  the  mouth,  295 

continuous,  293 

continuous  systematic,  293,  296 


Syphilis,      treatment     (jf,      cnderniic 
method  of,  294 
hypodermatic,  300 
intermittent,  293 
mercurial  fumigations,  299 
salvarsan,  315 
symptomatic,  293 
thermal  baths  in  the,  304 
tonic  dose  in  the,  296 ( 
vehicles  of  infection,  245 
Syphilitic  alopecia,  266 
treatment,  267 
dactylitis,  281,  282 
dyspnoea,  279 
dermatoses,  259 
ecthyma,  262 
epilepsy,  285 
erythema,  264 
iritis,  270 
Syphilis,  tertiary,  272 
Syphilodermata  (see  syphilides) 
Syphilophobia,  285 

Tabes  dorsalis,  syphilitic,  284  , 
Teale's  probe  gorget,  108 
Teeth,  Hutchinson's,  288 
Tendons,  syphilis  of,  280 
Teratoma  of  testicle,  206 
Tertiary  syphilis,  272 

affections  of  bone  in,  272,  280 
of  bronchi  in,  279 
epididymis,  281 
fingers,  281,  282 
intestines  in,  279 
larynx  in,  278 
lungs  in,  279 
muscles,  279 
oesophagus  in,  278 
periosteum  in,  272 
rectum  in,  279 
skin,  273 
spleen  in,  279 
stomach  in,  279 
testes,  281 
toes,  281 
etiology  of,  272 
lesions  of,  272 
secretions  of,  273 
Tertiary  syphilides,  273 
Test,  Esbach's  quantitative,  7 
methylene  blue,  228 
Noguchi's,  311,  312 


INDEX. 


357 


Test,  phloridzin,  228 
two-glass,  32 
for  albumin,  6 
bile,  9 
blood,  10 
indican,  6 
pus,  ID 
phosphates,  5 
sugar,  8 
urea,  5 
Wassermann's,  310 
Testes,  anatomy  of,  138 
carcinoma  of,  148 
castration,  149 
cystic  sarcoma,  148 
secretion  of,  12 
syphilisof,  281 
tuberculosis  of,  146 
prognosis,  147 
treatment,  148 
undescended,  149 
Thompson's  dilator,  use  of,  104 

stone  searcher,  200 
Tilden-Brown  cystoscope,  225 
Toes,  syphilis  of,  281 
Tongue,  sclerosis  of,  292,  277 
Torsion  of  spermatic  cord,  145 
Traumatism  of  bladder,  206 
of  kidney,  186 
of  ureter,  211 
Treponema  pallidum,  239,  240 
Tripper  faden,  10,  24 
Tubercle  bacilli  in  urine,  13 

technic  of  examining  for,  13 
Weichselbaum's  method,  13 
Tubercular  syphilides,  262,  274 

vesiculitis,  137 

Tuberculosis  of  bladder,  208 

of  prostate,  174 

tests,  146 

Tuberclosis,  renal,  189 

Tumors  of  bladder,  204 

cerebral,  in  syphilis,  284 
of  scrotum,  139 
of  kidney,  183 
of  penis,  78 
Turpentine  in  urine,  8 
Two-glass  urine  test,  32 

Undescended  testicle,  149 
Unna's  ointment,  use  of,  47 
Uratic  calculi,  199 


Urea,  Fowler's  test  for,  5 
Ureter,  catheterization  of,  224 
inflammation  of,  211 
sounding,  211,  224 
stone  in  the,  211 
stricture  of,  211 
traumatisms  of,  211 
Ureteritis,  211 

Urethra,  hemorrhage  from,  121 
female,  stricture  in,  86 
male,  anatomy  of,  80 

calculi  in,  84 

diagnosis  of,  84 

diagram  of,  82 

foreign  bodies  in,  84 
treatment  of,  85 

physiology  of,  80 
Urethral  fever,  115 
Urethrectomy,  112 
Urethritis,  abortive  treatment  of,  25 
acute  anterior,  23 
acute  posterior,  42 
argyrol,  use  of,  in,  29 
astringents,  use  of,  in,  29 
balanitis  in,  41 
bubo  in,  39 
chronic,  45 

etiology,  45 

diagnosis,  46 

discharges,  46 

infections,  46 

symptoms,  46 

synonyms,  45 

treatment,  47 

use  of  endoscope  in,  49 
complications  of, 

anterior  urethritis,  ^;^ 

posterior  urethritis,  43 
constitutional     disturbances     in, 
24 

treatment  of,  25 
copper  sulphate  in,  48 
Cowperitis  in,  36 
cystitis  in,  44 
etiology  of,  19,  23 
exacerbation    of    symptoms    in, 

33 
examination  of  urine  in,  31 
follicular  involvement  in,  46 
Guyon's  syringe,  use  of,  in,  47 
incubation  of,  19,  23 
in  female,  58 


358 


INDEX. 


Urethritis,   inflammation  of  preputial 
follicles  in,  35 
.    irrigations  in,  29 

Keyes-Ultzman   syringe,    use   of, 
in,  47 

Kollman's  dilator,  use  of,  in,  48 

local  treatment  of,  28 

lymphangitis  in,  41 

morning  drop  in,  46 

pathology  of,  23 

periurethral  infection  in,  35 

posterior,  42,  49 

posthitis  in,  41 

potassium  permanganate,  use  of, 
in,  30 

prognosis  of,  31 

protargol,  use  of,  in,  29 

relapses  in,  ^^ 

retention  of  urine  in,  27,  36 

rheumatism  in,  36 

simple,  19 

specific,  19 

stage  of  decline  of,  29 

symptoms,  24 

synonyms,  19 

tripper  faden  of,  24,  32 

two-glass  test  for,  32 

use  of  endoscope  in,  49 

varieties  of,  18 

vegetations  in,  41 
Urethrocystitis,  44 
Urethroscope,  use  of,  213 
Urinalysis  record,  17 
Urinary  calculi,  15 
Urine,  acid  fermentation  of,  9 

albumin  in,  7 
tests  for,  7 

amount  of,  2 

average  composition  of,  4 

bacillus  coli  communis  in,  13 

bacteria  in  the,  13 

biliary  pigment  in,  9 

blood  in  the,  10 

chlorides  in,  5 

color  of,  3 

casts  in  the,  1 1 

copaiba  in,  7 

echinococcus  cysts  in,  13 

epithelia  in,  12 

examination  of,  i 

extravasation  of,  114 

general  technic  for  examining,  i 


Urine,  gonococci  in,  9 

indican,  presence  of  in  the,  6 
micrococcus  urea  in,  2 
mucus  in,  9 
nocturnal  incontinence  of,  117 

treatment,  118 

atropia,  use  of,  in,  119 
by  epidural  injection,  119 
odor  of,  3 
phosphates  in,  5 
pseudo-membrane  in,  12 
pus  in  the,  10 
reaction  of,  2 
retention  of,  112 

diagnosis,  112 

symptoms,  112 

treatment,  113 
retention  of,  in  infants,  113 
sediments  in,  9 
segregators,  228 
seminal  vesicular    secretions    in, 

specific  gravity  of,  4 
Sugar  in,  8 

Fehling's  test  for,  8 
testicular  secretions  in,  12 
transparency  and  consistency  of,  4 
tubercle  bacilli  in,  13 
turpentine  in,  7 
urobihn  in,  3 

Vaginitis,  59 

Van  Hook's  operation,  211 

Varicocele,  150 

diagnosis,  150 

etiology,  150 

high  operation  for,  152 

open  operation  for,  150 

subcutaneous  ligation  for,  152 

symptoms,  150 

treatment,  151 
Vas  deferens,  anatomy  of,  138 
Vasotomy,  133 
VesicuHtis,  135 
^''egetations  on  the  penis,  41 
Venereal  warts,  41 
Verruca,  41 
Verumontanum,  general  description  of 

55 
inflammation  of,  55 
pathological  deformities  of,  56 
treatment  of  disease  of,  57 


INDEX. 


;59 


\'esical  calculus,  198 

diagnosis,  199 

symptoms,  199 

treatment,  200 
Vesiculitis,  seminal,  131,  132 

tubercular,  137 
diagnosis,  137 
treatment,  137 
Volkmann's  operation,  143 
Von  Bergmann's  operation,  144 
Vulvitis,  gonorrhoeal,  59 


Warts,  venereal,  41 
Weichselbaum's  method,  13 
Wheelhouse's  operation,  108 
X-ray,  lithiasis,  117  ' 

Young's  method  of  operation  in  car- 
cinoma of  prostate,  176 

Young's  modification  of  the  Bottini 
incision,  171 

Zinc  salts,  use  of,  in  urethritis,  29, 
333,  334 


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